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BOOK    6l4.H55   c.  1 

H'LL    *   NEW  ""BLIC   HEALTH 


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THE  NEW  PUBLIC  HEALTH 


THE  MACMILLAN  COMPANY 

NEW  YORK  •    BOSTON   -    CHICAGO  •   DALLAS 
ATLANTA  •    SAN  FRANCISCO 

MACMILLAN  &  CO.,  Limited 

LONDON  •    BOMBAY  •    CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  Ltd. 

TORONTO 


The  New  Public  Health 

BY 


HIBBERT  WINSLOW  HILL, 

M.  B.,   M.  D.,   D.  P.  H. 
Late    Director,    Division    of   Epidemiology,    Minnesota    State 
Board  of  Health,  and  later  Executive  Secretary,  Minne- 
sota    Public     Health     Association,     now     Director, 
Institute  of  Public  Health;  and  M.  O.  H.,  of 
London,     Canada;     Professor     of     Public 
Health,  Western  University. 


REPRINT   WITH   CORRECTIONS 


IFlew  l^orfe 

THE  MACMILLAN  COMPANY 
1925 

All  rights  reserved 


Copyright,  1916, 
By  THE  MACMILLAN  COMPANY. 


Set  up  and  electrotyped.     Published  February,  1916. 

in  is 


Berwick  &  Smith  Co.,  Norwood,  Mass.,  U.S.A. 


PREFACE 

The  conceptions  of  health,  public  and  private,  held  by 
our  ancestors  and,  until  very  lately,  by  ourselves,  have 
undergone  gradual  revision,  not  to  say  revolution,  in  the 
last  twenty  years;  changing  most  radically  perhaps  in 
the  last  ten.  The  Minnesota  State  Board  of  Health  in 
1911  designated  the  writer,  then  in  charge  of  the  Divi- 
sion of  Epidemiology  of  that  Board,  to  present  the 
modern  conceptions  to  the  medical  profession  and  to  the 
public.  A  series  of  articles,  which  appeared  monthly 
during  1912  in  the  Journal-Lancet  of  Minneapolis,  was 
the  outcome.  These  articles  were  furnished  by  the 
Journal-Lancet  to  1,100  newspapers  in  the  United 
States,  and,  during  the  latter  half  of  the  series,  to  fifty 
newspapers  in  Canada.  Finally  they  were  reprinted  in 
book  form  at  the  end  of  the  year.  So  cordial  was  their 
reception,  that  a  revision  and  expansion  of  the  articles 
thus  first  issued  has  been  undertaken  here. 

The  writer,  in  expressing  his  great  personal  debt  to 
the  State  Board  of  Health  of  Minnesota  for  making 
possible  this  beginning  and  to  the  Board  of  Governors 
of  the  Institute  of  Public  Health  of  London  for  its 
liberal  support  and  continuation,  would  mention  par- 
ticularly Dr.  W.  A.  Jones  and  Dr.  H.  M.  Bracken,  re- 


PKEFACE 

spectively  president  and  secretary  of  the  Minnesota 
State  Board  of  Health,  Drs.  B.  M.  Merrill  and  C.  F. 
More,  members  of  the  Censorship  Committee  of  that 
Board,  and  Mr.  W.  L.  Klein,  publisher  of  the  Journal- 
Lancet,  for  their  advice,  deep  personal  interest,  and 
cordial  co-operation.  To  Dr.  F.  F.  Wesbrook,  now 
President  of  the  University  of  British  Columbia,  then 
Director  of  the  Minnesota  State  Board  of  Health 
Laboratories,  to  Dr.  A*  J.  Chesley,  then  a  colleague, 
now  the  writer's  successor  in  the  Division  of  Epidemi- 
ology, to  Professor  F.  H.  Bass,  ex-Director  of  the  Divi- 
sion of  Sanitary  Engineering  of  the  Minnesota  State 
Board  of  Health,  to  Mr.  Christopher  Easton,  at  one 
time  Secretary  of  the  Minnesota  Anti-Tuberculosis 
Association,  to  Dr.  J.  P.  Sedgwick  of  the  Medical  De- 
partment of  the  University  of  Minnesota,  and  to  Pro- 
fessor S.  Quigley  of  the  Department  of  Pedagogy  of 
the  same  University,  the  writer  acknowledges  with 
pleasure  most  friendly  and  valuable  consultation  on  the 
more  technical  portions. 

It  is  not  possible  to  list  all  who  have  aided  the  writer 
directly  or  indirectly  in  this  work;  still  less  possible 
would  it  be  to  attempt  to  list  those  whose  appreciation 
and  good  wishes  made  the  work  a  pleasure.  But  it 
would  be  unseemly  to  omit  reference  to  one  other,  who 
was  unconnected  with  the  official  family  either  in  Min- 
nesota or  in  London.  The  great  reconstructing  force 
in  Public  Health  has  been  bacteriology,  but  the  applica- 
tion of  the  laboriously  sought  out  and,  to  Public  Health 


PREFACE 

principles,  in  general,  often  barren,  work  of  the  Bacteri- 
ologist, must  be  acknowledged  as  due  to  an  administrator 
of  keen  insight  and  logical  mind,  Dr.  Chas.  V.  Chapin 
of  Providence,  whose  "  Sources  and  Modes  of  Infec- 
tion "  marks  the  real  beginning  of  scientific  public 
health  in  America. 

That  this  book  may  further  aid  in  giving  to  all  who 
read  it  a  definite  view  of  the  chief  problems  of  public 
health,  and  of  their  chief  solutions,  is  the  aim  of  the 
writer ;  that  it  may  prove  a  satisfaction  to  many  friends, 
his  hope. 


CONTENTS 


CHAPTER  PAGE 

1     DEFINITIONS 1 

SUMMARY 5 

II    THE  OLD  PRINCIPLES  AND  THE  NEW  ...  7 

The  Revolution 7 

The  Old  Teachings 9 

The   New    Ideas 12 

Environment 14 

III  INFECTIOUS  DISEASES 17 

Facts 17 

(a)  Sources  of  Infectious  Diseases  .  .  .21 

(b)  Routes  of  Infectious  Diseases  ...  23 

(c)  Control  of  Infectious  Diseases  ...  24 

IV  WHY  DO  ANYTHING? 26 

How  Big  a  Problem  Is  It? 27 

Who  Keeps  the  Infectious  Disease  Going?    .  28 

Why  and  How  are  Women  Responsible?   .     .  29 

Present  Attempts 29 

Radical    Changes    in    Social    Conditions    the 

Real  Solution 30 

V    NON-INFECTIOUS  DISEASES 33 

Speculations 33 

Physical  Perfection 35 

The   General   Problem 36 

The  Present  Situation 39 

Immediate   Possibilities 42 

Education 45 


CONTENTS 

chapter  page 

Medical  Supervision  of  Schools 48 

Summary 50 

VI     EDUCATIONAL  MECHANISM 53 

Summary 61 

VII     THE  OLD  PRACTICE  AND  THE  NEW  ....  63 

Epidemiology 63 

Comparative   Methods 65 

The  New  Emergency  Epidemiology    ....  69 

Stopping  a  "  Primary  *  Epidemic 71 

Stopping  "Secondary"  Outbreaks      .      .      .      .73 

Finding  the  Unknown  Cases 75 

Summary 77 

VIII     THE  NEWEST  PRACTICE 79 

Concurrent   Epidemiology 79 

Future  Applications 84 

Chief     Infectious     Diseases,     Classified     by 

Routes 88 

The  New  Program 91 

IX     INDIVIDUAL  DEFENSE 95 

Public  Defense  and  Private 95 

The    Preventability    of    the    "  Preventable  " 

Diseases 96 

"Dodging    Infection" 100 

Contact-Infection 101 

Placard  for  Schools 107 

Summary 112 

X     COMMUNITY  DEFENSE 114 

The  Public  Health  Engineer 114 

Summary 122 

XI     COMMUNITY  DEFENSE 124 

The  Public  Health  Laboratory 124 

Summary 131 


CONTENTS 

CHAPTER  pAGE 

XII     COMMUNITY  DEFENSE 133 

The  Public  Health  Statistician 133 

Statistics  as  They  Will  Be 134 

Statistics  as   They  Abe 138 

Summary 147 

XIII  ADMINISTRATION 148 

Summary 156 

XIV  COMMUNITY  DEFENSE  APPLIED 158 

Tuberculosis   in   General 158 

Human  Tuberculosis 159 

The   Abolition   of   Cattle   Tuberculosis    from 

the  Human         163 

The  Abolition  of  Human  Tuberculosis  .      .      .163 
Summary 170 

XV    THE     CONTROL     OF     DIPHTHERIA,     SCARLET 

FEVER  AND  MEASLES 173 

Summary 176 

XVI     VENEREAL  DISEASES 178 

XVII     THE  CONCLUSION  OF  THE  WHOLE  MATTER   .    182 

The  Doing  of  It 182 

The   Chief   Objections 185 

Popular   Fallacies 189 

New    Fashioned   Quarantine 190 

Summary 192 

APPENDIX  I.    Condensed    Data    on    Infectious 
Diseases        195 

APPENDIX  II.     Syllabus      of     Public      Health 
Teaching 197 


THE  NEW  PUBLIC  HEALTH 

CHAPTER  I 
DEFINITIONS 

Public  Health  is  a  term  which  includes  all  knowl- 
edge and  all  measures  tending  to,  (a)  foster  health  or 
(b)  to  prevent  disease. 

These  two  objects  are  far  from  identical.  True,  cer- 
tain personal  measures  to  promote  health,  classed  under 
hygiene,  i.e.,  proper  care  and  cultivation  of,  say,  the 
muscles,  necessarily  also  avoids  those  "  diseases,"  which 
may  result  from  neglect  or  misuse  of  those  muscles ;  in- 
cidentally, perhaps,  of  other  parts  of  the  body  also.  To 
care  for  properly  and  develop  sight  to  its  highest  effi- 
ciency necessarily  includes  eliminating  the  train  of 
evils  connected  with  eye  strain.  But  such  cultivation 
of  the  body  forces  to  secure  high  efficiency  will  not  and 
cannot  prevent  those  accidents  or  diseases  which  origi- 
nate from  outside  sources.  A  bullet  will  travel  equally 
as  far  through  the  soldier  who  is  physically  perfect  as 
through  him  who  is  a  physical  wreck. 

Public  Health  may  be  divided  into  Hygiene  and 
Sanitation.     Hygiene  deals  with  the  individual   and 


2  THE  NEW  PUBLIC  HEALTH 

his  physical  perfection.  The  causes  and  sources  of 
those  diseases  which  come  from  the  outside,  from  the 
surroundings  of  the  individual,  are  dealt  with  under  the 
term  Sanitation.  Just  as  Hygiene  deals  with  meas- 
ures which  (a)  promote  health  and,  some  of  them  (b) 
prevent  disease,  so  Sanitation  also  presents  two  sub- 
divisions, the  measures,  dealing  with  surroundings, 
which  intrinsically  (a)  promote  health  or  (b)  prevent 
disease.  Thus,  proper  ventilation,  while  securing  the 
best  available  conditions  for  the  body  so  far  as  atmos- 
pheric surroundings  are  concerned,  necessarily  elimi- 
nates those  "  diseases  "  which  might  arise  from  the  re- 
action of  the  body  to  "  poor  ventilation,"  and  so  far 
Sanitation  and  Hygiene  are  intimately  interdependent. 
But  good  ventilation,  although  invaluable  to  the  gen- 
eral welfare  and  efficiency  of  the  body,  has  no  necessary 
relation  to  the  elimination  of  certain  outside  injurious 
forces,  such  as  lead  poisoning  or  alcoholism  or  accidents 
or  invasions  of  the  body  by  micro-organisms.  Each  of 
these  must  be  met  by  specific  measures,  adapted  to  the 
elimination  of  the  particular  factor  involved.  More- 
over, such  specific  measures  will  eliminate  the  specific 
trouble,  whether  such  general  physical  efficiency  and 
high  health  as  may  be  secured  through  good  ventilation 
be  secured  or  not. 

The  greatest  advance  made  of  recent  years  in  public 
health  is  the  generalization  from  such  facts,  long 
known  in  detail,  that  measures  promoting  bodily  health 
and  efficiency  do  not  necessarily  eliminate  those  ex- 


DEFINITIONS  3 

temal  and  insidious  factors  of  disease  by  invasion  from 
without,  particularly  of  the  invaders  which  produce  the 
infectious  diseases. 

A  third  relationship,  long  believed  and  taught  as 
existing  between  the  measures  for  promoting  health  and 
those  for  eliminating  disease,  is  fast  losing  its  alleged 
importance.  This  belief  is  that  which  regards  high 
health  as  not  indeed  abolishing  infection,  but  as  con- 
ferring an  immunity  against  infectious  diseases.  It  is 
beginning  to  be  recognized  that  as  "  good  ventilation  " 
does  not  eliminate  "  eye  strain/'  as  good  lighting  does 
not  correct  "  poor  ventilation,"  so  all  through  hygiene 
and  sanitation  specific  troubles  must  be  met  by  specific 
measures  directed  specifically  against  the  real  specific 
cause  of  that  trouble.  Taught  for,  lo  these  many  years, 
that  general  cleanliness  is  a  protection  against  disease, 
we  are  beginning  to  realize  that  only  a  specific  cleanli- 
ness, that  which  actually  eliminates  disease  germs,  is  of 
real  value  for  this  purpose;  taught  also  that  general 
high  health  protects  against  disease,  we  are  beginning 
to  understand  that  the  only  form  of  bodily  condition 
which  secures  this  end  is  the  possession  by  the  body  of  a 
specific  protection  against  each  specific  disease.1  Even 
should  we  admit  that  perfect  health  may  theoretically 

i  It  is  far  from  certain  that  the  process  of  securing  such 
specific  immunity  through  an  attack  of  the  disease  in  question 
does  not  involve  permanent  damage  to  the  body  incompatible 
with  the  subsequent  attainment  of  the  highest  physical  perfec- 
tion. 


4  THE  NEW  PUBLIC  HEALTH 

prevent  the  inroads  of  smallpox  or  typhoid  fever  or  pneu- 
monia or  colds,  we  would  also  have  to  admit  that  such 
high  health  is  very  readily  upset,  by  a  chill,  a  missed 
dinner,  a  day's  overwork,  a  temporary  indigestion; 
and  since  this  is  so,  that  the  protection  against  infec- 
tion afforded  by  such  high  health,  if  it  exist  at  all,  is  too 
vague  and  uncertain,  too  subject  to  sudden  alterations 
and  even  complete  loss,  to  be  worthy  serious  considera- 
tion as  a  real  factor  in  the  control  of  disease,  in  ordi- 
nary life.  The  value  of  high  health,  of  hygiene,  lies 
in  the  physical  efficiency  and  bodily  comfort  which  it 
bestows ;  in  the  sense  of  well  being,  in  the  energy,  alert- 
ness and  keenness  which  result  from  it.  That  it  does 
not  protect  against  infection,  that  it  actually  indirectly 
contributes  to  infection  from  the  very  fact  that  the 
energy  and  alertness  it  bestows  take  its  possessor  out 
where  infection  lies  awaiting  him,  does  not  lessen  its 
real  value,  but  only  makes  the  removal  of  the  infection 
itself  an  even  more  important  duty  to  the  race.  The 
man  of  "  torpid  liver  "  and  bleary  eye,  the  muscular 
wreck,  lacks  that  vigor  and  aggressiveness  which  carry 
the  possessor  of  high  health  out  into  the  busy  haunts  of 
men  and  women ;  and  to  the  extent  that  he  escapes  con- 
tact with  his  fellows,  he  tends  to  escape  infection,  just 
as  the  invalided  soldier  escapes  the  effects  of  bullets  by 
not  encountering  them. 

To  hold  that  weaklings  only,  or  principally,  suffer 
from  diseases  of  this  nature  is  to  hold  a  view  which 
represents  a  complete  reversal  of  the  facts;  indeed,  if 


DEFINITIONS  5 

this  view  were  true,  infectious  diseases  would  long  since 
have  weeded  out  all  such  weaklings  and  left  a  race  of 
physically  perfect  giants,  free  from  all  diseases  be- 
cause of  their  exceeding  physical  perfection;  whereas 
exactly  the  contrary  is  true,  and  we  hear  the  cry  every- 
where that  physical  degeneracy  is  the  bane  of  modern 
citizenship.  Scarcely  one-fifth  of  the  young  men  ex- 
amined for  the  U.  S.  army  meet  the  much  modified 
army  requirements  as  to  physique;  moreover,  that  se- 
lected fifth,  disciplined,  exercised,  fed  and  cared  for  at 
the  highest  level  of  hygiene  that  we  know  succumbs  to 
infections  quite  as  easily  as  their  rejected  brothers;  and 
modern  armies  find  high  health  and  physical  develop- 
ment so  little  a  protection  against  these  infections  that 
every  new  specific,  like  vaccination,  is  seized  upon 
eagerly  to  take  its  alleged  place.  Surely  it  is  time  to 
cease  misleading  the  public  and  ourselves  with  a  will-o'- 
the-wisp  since  the  very  teachers  that  lend  their  weight 
to  the  doctrine  find  in  practice  that  no  high  health  they 
can  compass  for  their  trained  armies  protects  those 
armies  in  any  adequate  sense. 

SUMMAKY 

Modern  Public  Health  recognizes  that  health  means 
much  more  than  the  mere  absence  of  disease ;  and  under 
Hygiene  classes  all  measures  to  secure  the  best  internal 
workings  of  the  human  frame  to  keep  it  at  its  best; 
thus  eliminating  the  internal  poisonings,  and  the  re- 
sults of  deprivations  and  excesses  which  produce  cer- 


6  THE  NEW  PUBLIC  HEALTH 

tain  diseases  or  disabilities.  But  it  recognizes  further 
that  surroundings,  through  direct  action  on  the  body, 
perfect  or  imperfect,  may  injure  or  destroy  the  best 
just  as  the  worst ;  and  under  Sanitation,  strives  to  pro- 
vide surroundings  which  may  eliminate  external  condi- 
tions leading  to  disease  or  injury. 

The  chief  advance  of  recent  years  is  that  which  recog- 
nizes the  specificity  of  cause  and  effect,  both  in  Hygiene 
and  in  Sanitation;  and  meets  each  separate  source  or 
cause  of  each  such  trouble  with  a  specific  measure  to 
prevent  it. 

Against  the  visible  outside  causes  of  disease,  those 
causes  which  can  be  seen  and  recognized  by  every  one, 
(the  chemical  poisons,  accidents,  etc.),  the  weapons  are 
education  and  elimination  or  proper  handling  of  those 
causes,  if  they  cannot  be  eliminated. 

Against  the  invisible  and,  to  the  general  public,  un- 
recognizable causes  which  produce  the  infectious  dis- 
eases, the  warfare  must  necessarily  be  directed  to  their 
elimination,  under  such  preliminary  education  as  will 
permit  the  establishment  of  the  necessary  mechanisms. 


CHAPTER  II 
THE  OLD  PRINCIPLES  AND  THE  NEW 

THE   REVOLUTION 

The  statement  that  there  is  a  "  New  Public  Health  " 
may  shock  those  who,  although  familiar  with  recent 
changes  in  scientific  thought,  yet  have  not  fully  realized 
what  those  changes  mean;  but  the  shock  will  be  far 
greater  to  those  who  have  not  appreciated  that  changes 
were  going  on. 

The  purpose  of  the  writer  is  to  formulate  for  both 
groups,  the  unconscious  progressive  and  the  unconscious 
conservative,  a  brief  statement  of  the  essential  prin- 
ciples of  modern  professional  public  health  work  relat- 
ing to  the  prevention  of  disease.  To  those  who  may 
feel  skeptical  as  to  the  fairness  of  this  exposition,  the 
writings  of  Chapin,  the  great  American  pioneer  of 
modern  public  health,  of  E.  O.  Jordan,  and  of  M.  N. 
Baker,  may  be  offered  as  bearing  directly  upon  these 
questions,  while  the  whole  of  modern  technical  public- 
health  literature  may  be  offered  as  indirect  evidence. 
Since  the  infectious  diseases  constitute  the  chief  as  well 
as  the  best  understood  group  of  preventable  diseases  or 
causes  of  death  and  disability,  the  infectious  diseases 
are  here  chiefly  discussed. 

7 


8  THE  NEW  PUBLIC  HEALTH 

The  old  principles  have  merged  gradually  into  the 
new,  in  keeping  with  the  experiments,  observations, 
and  conclusions  of  many  investigators  in  many  indi- 
vidual sciences  related  to  general  public  health. 
Within  professional  public-health  circles,  bacteriology, 
clinical  observation,  and  mathematics  have  furnished 
most  of  the  reconstruction.  The  bacteriologist,  the  epi- 
demiologist, and  the  vital  statistician,  sometimes  work- 
ing together,  more  often  alone,  in  the  dark  and  even 
at  cross  purposes,  have  nevertheless  all  reached  the  same 
point,  and  to-day  each  finds  his  co-workers  beside  him. 
Much  of  the  work  done  has  consisted  in  clearing  away 
the  fallacies  built  up  by  tradition,  but  construction- 
work  has  gone  on  also,  and  it  is  now  possible  to  formu- 
late the  results. 

The  essential  change  is  this:  The  old  public  health 
was  concerned  with  the  environment;  the  new  is  con- 
cerned with  the  individual.  The  old  sought  the  sources 
of  infectious  disease  in  the  surroundings  of  man;  the 
new  finds  them  in  man  himself. 

The  old  public  health  sought  these  sources  in  the  air, 
in  the  water,  in  the  earth,  in  the  climate  and  topog- 
raphy of  localities,  in  the  temperature  of  soils  at  four 
and  six  feet  deep,  in  the  rise  and  fall  of  ground-waters ; 
it  failed  because  it  sought  them,  very  painstakingly  and 
exhaustively,  it  is  true,  in  every  place  and  in  every 
thing  where  they  were  not. 

The  new  public  health  seeks  these  sources  —  and 
finds  them  —  amongst  those  infective  persons  (or  ani- 


OLD  PKIBTCIPLES  AM)  NEW  9 

mals)  whose  excreta  or  other  constituents  or  body  con- 
tents enter  the  bodies  of  other  persons. 

The  old  public  health  failed  to  find  the  sources  of  in- 
fection; it  also  failed  in  most  instances  to  find  the 
routes  of  transmission.  It  is  true  that  public  water- 
supplies  were  detected  as  at  times  transmitting  infec- 
tion ;  but  milk  was  hardly  suspected  twenty  years  ago ; 
flies  (and  other  insects),  suggested  in  1887, x  were  not 
seriously  considered  until  the  Spanish- American  war; 
mouth-spray  2  and  hands  have  been  only  recently  recog- 
nized as  important.  On  the  other  hand,  dirty  clothes, 
bad  smells,  damp  cellars,  leaky  plumbing,  dust,  foul 
air,  rank  vegetation,  swamps,  stagnant  pools,  certain 
soils,  smoke,  garbage,  manure,  dead  animals,  in  fact 
everything  physically,  sensorially,  esthetically,  or 
psychically  objectionable,  were  lumped  together  as  "  un- 
sanitary "  without  much  distinction  of  "  source "  or 
"  route,"  and  were  regarded  as  a  sort  of  general  "  cause 
of  disease  "  to  be  condemned  wherever  found,  "  for  fear 
of  epidemics." 

THE    OLD    TEACHINGS 

It  was  taught  that  infectious  diseases  "  generated  "  in 
the  foul,  ill-smelling,  unventilated,  sunless  hovels  of  the 
slums.     In  the  vogue  of  those  days,  "  the  slum-dwellers 

i  Wm.  H.  Welch :  Address  at  the  Annual  Meeting  of  the  Medi- 
cal and  Chirurgical  Faculty  of  Maryland  1887,  quoted  in  Sewage 
and  Local  Drainage. —  Waring,  1889. 

2  By  this  is  meant  the  fine  droplets  thrown  out  from  the  mouth 
in  speaking,  singing,  laughing,  sneezing,  coughing,  etc. 


10  THE  NEW  PUBLIC  HEALTH 

live  like  pigs,  and  thereby  invoke  the  coming  of  small- 
pox, scarlet  fever,  typhoid  fever,  diphtheria."  When 
these  diseases  invaded  the  home  of  the  well-to-do,  where 
this  explanation  was  not  seemly,  a  pinhole  leak  in  some 
plumbing  fixture  accounted  amply  for  diphtheria;  rot- 
ten potatoes,  forgotten  in  a  dark  corner  of  the  cellar, 
for  typhoid  fever;  scarlet  fever  was  traced  to  a  letter 
bearing  "  scales  "  from  a  friend  who  had  had  the  dis- 
ease months  before;  smallpox  to  unpacking  books  used 
by  a  patient  a  quarter  of  a  century  previously ;  manure 
piles  gave  rise  to  cholera;  and  dampness  to  malaria, 
which  was  not  recognized  as  transmissible  at  all.  Yel- 
low fever  originated  in  impure  water  and  was  directly 
transmitted  from  person  to  person  —  a  typical  example 
of  intense  direct  contagion ;  tuberculosis  was  non-infec- 
tious and  hereditary ;  bubonic  plague  was  banished  from 
the  Egyptian  Cairo  "  simply  by  improving  the  ventila- 
tion of  the  city"  (!)3 

Eemedial  and  preventive  measures,  based  on  such 
beliefs  in  the  omnipotence  of  environment,  naturally 
sought  to  remodel  the  lives  and  immediate  home  sur- 
roundings of  the  whole  population  to  conform  with  a 
vast  array  of  alleged  "  sanitary  laws  of  health."  Yet 
he  who  seeks  for  a  scientific  demonstration  of  the  rela- 
tions existing  between  disobedience  of  these  "  sanitary 
laws"  on  the  one  hand,  and  the  incidence  of  disease 
and  death  on  the  other,  will  find  only  a  "  twilight  zone  " 

s  Parke's  Hygiene,  1891 ;  eighth  edition.  This  was  a  standard 
work  of  twenty-five  years  ago. 


OLD  PKINCIPLES  AND  NEW  11 

in  which  move  vague  shadows  of  traditional  fear,  shad- 
ows which,  on  probing,  fade  mistily  away.4 

While  admitting  freely  that  almost  any  item  of  an 
environment  may  act  as  a  route  of  infection,  at  odd 
times,  or  under  peculiar  conditions,  the  New  Public 
Health  is  not  worried  by  elaborate  theoretical  possibili- 
ties, but  concerns  itself  earnestly  with  practical  proba- 
bilities. The  occasional,  unusual,  bizarre  routes  of  in- 
fection in  the  1  per  cent,  of  cases,  do  not  distract  its 
attention  from  the  usual,  practically  constant,  simple, 
ordinary  routes  concerned  in  the  99  per  cent. 
Its  main  postulate  is  that  the  routes  of  infection  are 
simply  the  routes  of  infected  bodily  discharges,  which, 
again,  are  identical  with  the  routes  of  ordinary  unin- 
fected discharges  in  ordinary  life;  and  that  if  the 
99  per  cent,  of  commonplace  cases  are  prevented,  the 
1  per  cent,  will  not  occur  at  all.  Too  often  attention 
has  been  riveted  on  extreme  precautions  to  avoid  the 
1  per  cent.,  and  no  precautions  worthy  of  the  name 
have  been  directed  to  avoidance  of  the  99  per  cent. 

The  old  style  "  sanitary  inspector  "  was  expected  to, 
and  usually  did,  "  condemn  "  everything  in  sight,  from 
the  garbage  pail  at  the  back  door  to  the  plumbing  in  the 
bath-room.  But  disease  continued,  because  he  was  con- 
demning, as  a  rule,  so  far  as  health  was  concerned, 
things  largely  "  incompetent,  irrevelant  and  imma- 
terial." What  availed  it  that  the  garbage-pail  was 
emptied  every  day  or  a  vent-pipe  placed  on  the  bath- 

*  See  Journal-Lancet  of  July  15,  1914. 


12  THE  NEW  PUBLIC  HEALTH 

water  waste-trap,  if  the  milkman  delivered  scarlet-fever- 
infected  milk  at  the  door,  or  an  unrecognized  case  of 
measles  sat  next  the  children  at  school? 

The  wooden  knight  of  Alice  in  Wonderland  who 
carried  a  mouse  trap  on  horseback  because  mice  might 
some  day  infest  his  horse,  while  riding  so  badly  that  he 
continually  fell  off  on  his  head  and  was  as  continually 
in  process  of  being  restored  to  his  saddle  by  kind 
friends,  furnishes  the  most  kindly  yet  realistic  satire 
on  prevailing  public-health  methods  that  could  well  be 
devised. 

THE    NEW    IDEAS 

The  JSTew  Public  Health  sees  in  the  garbage-pail 
merely  a  place  where  flies  are  fed  and,  possibly,  bred. 
But  the  flies  cannot  carry  infection  if  infected  dis- 
charges are  not  accessible  to  them. 

The  Old  regarded  the  garbage-pail  as  in  itself  and  by 
itself  intrinsically  bad,  disease-producing  and  deleteri- 
ous to  health.  This,  notwithstanding  that  employes  in 
garbage-collection,  garbage-destruction  or  garbage-ren- 
dering work  average  as  healthy  a  body  of  men  as  any 
others  of  similar  status. 

"  Defective  plumbing,"  such  a  nightmare  twenty 
years  ago,  has  been  conclusively  shown  to  have  nothing 
to  do  with  disease-generation  or  disease-propagation 
whatever,  unless  perchance  there  be  actual  gross  leak- 
age of  infected  sewage.  The  employees  connected  with 
great  sewage  systems,  even  those  continually  employed 


OLD  PKINCIPLES  AND  NEW  13 

in  the  great  sewers  of  large  cities,  average  well,  like 
garbage  workers,  as  to  incidence  of  disease  amongst 
them. 

The  unventilated  front  parlor  could  not  produce 
tuberculosis  in  a  hundred  years;  diphtheria  does  not 
develop  from  the  family  well  despite  many  a  well-meant 
tirade  on  its  evils;  and  typhoid  fever,  in  sand  or  clay 
areas,  is  but  seldom  properly  traceable  to  that  source, 
either.  Stagnant  or  old,  longstanding  water,  is  to  this 
day  often  considered  responsible  for  typhoid,  despite 
the  definite  knowledge  that  no  system  of  purification  of 
typhoid-infected  water  is  more  reliable  than  impound- 
ing, which  is  merely  keeping  it  standing ! 

The  modern  public  health  man  cares  nothing,  so  far 
as  restriction  of  disease  and  death  is  concerned,  for  the 
dirty  back  yard  or  the  damp  cellar  in  themselves,  but 
only  as  they  may  enter  into  the  transmission  of  infected 
discharges.  Then,  at  once,  they  become  of  vital  impor- 
tance. The  sanitary  inspection  of  the  modern  sani- 
tarian, so  far  as  relates  to  infection,  begins  and  usually 
ends  with  the  search  for  (a)  the  infected  individual; 
(b)  the  routes  of  spread  of  infection  from  that  indi- 
vidual; (c)  the  routes  of  spread  of  the  ordinary  excreta 
of  ordinary  uninfected  individuals  to  the  mouths  of 
their  ordinary  associates  in  ordinary  life.  These  latter 
are  sought  for,  not  because  of  danger  from  such  unin- 
fected discharges,  but  rather  because  infected  dis- 
charges, introduced  into  and  following  the  same  well- 
beaten  paths,  will  necessarily  reach  the  same  mouths. 


14  THE  NEW  PUBLIC  HEALTH 

To  locate  all  the  infective  persons  and  to  guard  all  their 
discharges  would  be  wholly  sufficient  and  is  the  ulti- 
mate goal  of  modern  preventive  measures,  but  since  this 
cannot  always  be  done  perfectly,  it  is  well  to  guard  also 
the  routes  which  unlocated  infection  may  take. 

ENVIRONMENT 

Has  environment,  then,  nothing  to  do  with  infec- 
tious diseases  ?  Environment  acts  in  two  ways :  Eirst, 
unequivocally  and  without  reserve,  such  environments 
as  permit  or  encourage  or,  still  worse,  necessitate  the 
exchange  of  human  excreta  in  ordinary  life,  contribute 
in  the  long  run  to  the  spread  of  disease  since  they  in- 
sure a  similar  exchange  of  infected  excreta  so  soon  as 
the  latter  are  introduced.5  Let  us  take  one  environ- 
mental evil,  overcrowding,  as  an  example.  Overcrowd- 
ing, if  combined  with  lack  of  discipline  and  order,  and 
lack  of  facilities  for  washing,  especially  for  the  washing 
of  hands,  contributes  to  the  spread  of  infectious  dis- 
eases; but  not  in  itself;  nor  at  all,  unless  infection  be 
introduced  into  the  community.  Then  overcrowding, 
because  it  tends  to  insure  exchange  of  human  excreta, 
tends  also  to  insure  that  the  infection  will  spread  rap- 
idly and  extensively.  But  overcrowding,  if  the  over- 
crowded be  disciplined,  intelligent,  and  take  proper  pre- 
cautions to  avoid  exchange  of  excreta,  does  not  necessi- 

s  An  excellent  exposition  of  this  effect  of  environment  on  the 
spread  of  disease  is  given  by  Chapin  in  the  Report  of  the  Provi- 
dence Health  Department  for  1910. 


OLD  PKINCIPLES  AND  NEW  15 

tate  the  spread  of  infection,  even  if  it  be  introduced. 
On  the  other  hand,  infection  may  spread,  and  fre- 
quently does,  without  overcrowding,  if  the  essential 
factor  of  such  spread  exist,  i.e.,  the  transmission  of  in- 
fected excreta. 

Second.  Environments  that  are  bad  from  a  physi- 
ological standpoint  (bad  for  the  body,  regarded  as  a 
delicate  biological  machine)  are  often  held  to  act  in 
spreading  infection  indirectly  by  "  depressing  vitality  " 
to  an  extent  which  makes  infection,  if  received,  more 
likely  to  develop  (and  if  it  develop,  more  successful  in 
injuring  the  body).  It  must  be  said,  however,  that  the 
evidence  on  this  point,  except  perhaps  that  relating  to 
tuberculosis  and  pneumonia,  is  very  slight.  It  is  a 
debatable  question  whether  or  not  overcrowding  "  de- 
presses vitality  "  in  the  direction  of  increasing  suscepti- 
bility to  infectious  diseases,  whatever  its  effect  may  be 
in  encouraging  "  general  debility."  It  is  a  very  de- 
batable question  whether  or  not  "  poor  ventilation,"  to 
which  the  effects  of  overcrowding  are  often  attributed, 
can  or  does  "  depress  vitality  "  in  the  direction  of  les- 
sening resistance  to  infectious  diseases,  whatever  bad 
effects  it  may  have  on  mental  vigor  or  physical  activity. 
It  is  true  that  there  is  evidence  that  such  environments 
as  lead  to  extremes  (beyond  the  limits  of  compensatory 
adjustments  by  the  body  forces)  of  mal-nutrition,  of 
temperature,  of  fatigue,  and  of  alcoholism,  probably 
may  have  an  effect  in  insuring  the  development  of  infec- 
tion, which  under  better  conditions  might  be  negatived 


16  THE  NEW  PUBLIC  HEALTH 

by  the  body  forces.  Especially  may  these  forms  of  bad 
physiological  environment  be  influential  when  the  dose 
of  infection  is  small,  infrequent,  or  low  in  virulence, 
for  it  is  conceivable  that  under  good  environment  the 
body  might  "  throw  them  off  more  readily."  But  star- 
vation, unsuitable  temperature,  fatigue,  alcoholism, 
alone  or  together,  cannot  induce  infection,  nor  will  the 
converse  conditions,  alone  or  together,  offset  the  effects 
of  infection  when  the  dose  is  large  or  frequently  re- 
peated or  of  high  virulence. 


CHAPTER  III 
INFECTIOUS  DISEASES 

FACTS 

It  would  appear,  then,  that  environment  as  affecting 
bodily  functions  has  little  to  do  directly  with  the  inci- 
dence of  most  of  the  specific  infections,1  notwithstand- 
ing that  nutrition,  temperature,  fatigue,  and  alcohol- 
ism are  generally  credited  with  some  effect,  especially 
in  pneumonia  and  tuberculosis. 

Damp,  cold,  and  fatigue  perhaps  precipitate  the 
pneumonias,  although  the  relation  is  not  clear,  and  of 
course  no  such  effect  is  observed  unless  one  of  the  in- 
fective agents  be  present.  The  environments  if  there 
be  such  at  all,  that  precipitate  tuberculosis  constitute  a 
problem  as  yet  unsolved.  Very  much  is  widely  be- 
lieved, and  even  more  is  freely  taught,  concerning  this 
subject,  but  the  evidence  is  tangled  and  often  contra- 

i  The  terms  contagious  and  infectious  were  formerly  carefully 
used  and  carefully  distinguished.  Modern  writers,  however,  fail 
to  find  any  useful  or  basic  significance  in  "  contagious  "  as  con- 
trasted with  "  infectious."  Hektoen,  in  Osier's  Modern  Medicine, 
discards  "  contagious  "  and  "  contagion  "  entirely. 

In  these  articles  "  infectious  "  is  used  to  mean  "  transmissible  " 
or  "  communicable." 

17 


18  THE  NEW  PUBLIC  HEALTH 

dictory.  "  Poor  ventilation,"  dust,  dampness,  etc., 
have  all  been  accused,  but  very  little  has  been  proved 
concerning  the  real  factors  actually  at  work  or  their 
mode  of  operation.  In  the  other  infectious  diseases  the 
effects  even  of  extremes  of  the  above  factors  are  but 
rarely  definitely  recognizable. 

Smallpox  is  contracted  or  escaped  in  exact  ratio  to 
the  degree  of  exposure  acting  in  opposition  to  the  de- 
gree of  specific  immunity.  No  other  known  environ- 
mental factor,  even  acute  alcoholism,  is  recognized  as 
influential. 

One  thing,  and  one  thing  only,  is  absolutely  estab- 
lished, namely,  that  tuberculosis,  microbic  pneumonia, 
and  the  other  infectious  diseases  will  develop  under 
almost  any  circumstances  if  the  dose  of  infection  be 
large  enough,  virulent  enough,  or  sufficiently  repeated. 
Tuberculosis,  microbic  pneumonia,  and  the  other  in- 
fectious diseases  will  not  develop  under  any  circum- 
stances without  such  infection. 

Hence  it  must  be  evident  that  the  sine  qua  non  of  all 
infectious  diseases  are  their  respective  agents,  and  that, 
since  the  chief  sources  (infective  persons)  of  these  are 
known,  the  most  logical  efforts  are  those  which  concen- 
trate on  the  prevention  of  the  dissemination  of  these 
agents  from  these  sources. 

This  is  tenable,  not  only  in  theory,  but  in  practice, 
and  presents  an  infinitely  simpler  administrative  prob- 
lem than  that  presented  by  the  older  hypotheses, —  not 
only  in  the  "minor"  infectious  diseases,  where  these 


INFECTIOUS  DISEASES  19 

principles  have  been  practically  accepted  by  all,  but 
even  in  tuberculosis  itself. 

Thus,  if  "  general  environment "  be  the  great  factor 
in  tuberculosis,  the  hundred  million  people  of  these 
United  States  must  have  each  his  or  her  own.  individual 
environment  brought  up  to  and  kept  at  some  standard- 
level  designed  to  maintain  each  individual  in  his  or 
her  own  alleged  "  highest  state  of  health." 

If,  however,  the  infectiveness  of  the  disease  be  the 
great  factor,  only  200,000  people  (the  actively  infective 
cases)  need  this  supervision  in  the  United  States,  and 
they  need  it,  not  for  the  improvement  of  their  "  general 
environment,"  but  merely  to  prevent  them  from  infect- 
ing others.  This  problem,  even  numerically,  is  but  one 
three-hundredth  the  magnitude  of  the  other.  Consider 
the  utterly  impracticable  expense  and  difficulty  of  the 
attempt  to  insure  only  the  four  quoted  factors, —  good 
food,  proper  temperatures,  temperance,  and  repose, — 
to  one  hundred  million  people  (to  say  nothing  of  the 
other  "  factors  of  safety  "  called  for  by  those  who  lay 
chief  emphasis  on  control  of  environment,  i.e.,  abolition 
of  foul  air,  smoke,  dust,  damp  cellars,  bad  smells,  dirty 
back  yards,  etc.),  and  contrast  with  this  the  expense  of 
supervision  of  three  hundred  thousand  people  merely  to 
the  extent  of  confining  their  infective  discharges  to 
themselves. 

Further  consider  that  the  same  official  mechanism 
which  could  control  the  tuberculous  could  also  handle 
with  but  slight  expansion  the  infectious  persons  need- 


20  THE  NEW  PUBLIC  HEALTH 

ing  supervision  for  the  prevention  of  all  the  other  infec- 
tious diseases,  except  the  venereal,  as  well  as  the  infec- 
tive tuberculous.  Eemember  also  that  improvement 
of  the  "  general  environment,"  allowing  that  its  effec- 
tive achievement  were  conceivable,  could  not  be  ex- 
pected to  have  any  noteworthy  effect  on  most  of  these 
other  infectious  diseases,  even  though  it  had  some  on 
tuberculosis. 

]STeed  any  more  be  said  to  indicate  the  superiority  of 
the  new  principles,  as  practical  business  propositions, 
over  the  old  ? 

The  stumbling-block  is  that  the  general  public  still 
believes  the  teachings  of  thirty  years  ago  concerning 
environment.  These  teachings  were  a  mixture  of  the 
"  old-wives  fables "  of  the  prebacterial  age,  with  the 
early  incongruities  and  half-truths  of  the  new  "  theory  " 
of  bacteriology. 

Bacteriology  is  now  an  old-established  science;  but 
despite  the  fact  that  it  has  changed  public-health  work 
even  more  than  it  has  changed  medicine  or  surgery, — 
and  both  of  these  it  has  completely  revolutionized, —  the 
public  still  clings  to  the  belief  that  public  health  is  a 
curious  profession,  absorbedly  interested  in  cutting 
weeds  in  vacant  lots  ("to  prevent  epidemics"),  in 
burying  dead  animals  and  suppressing  noisome  odors 
("  to  prevent  epidemics  ")  ;  in  inspecting  plumbing  and 
collecting  garbage  ("to  prevent  epidemics").  The 
"  good  "  health  officer  according  to  the  popular  stand- 
ard, still  too  prevalent,  is  he  who  keeps  the  streets  clean 


INFECTIOUS  DISEASES  21 

and  the  back  alleys  neat,  who  falls  into  a  rapture  over  a 
newly  whitewashed  outhouse  and  into  a  rampage  if  a 
pile  of  old  bones  is  found  under  the  cellar  steps.  Yet 
many  of  those  who  know  better  let  these  ideas  alone,  or 
even  acquiesce  in  them,  "  to  save  trouble."  Xeverthe- 
less  it  is  expected  that  the  thus  carefully  uneducated, 
or  miseducated,  public  opinion  will  demand  up-to-date 
action !  Is  it  any  wonder  that  the  public  insists  on 
thinking,  acting,  and  legislating  to  suit  the  theories  of 
twenty  years  ago  instead  of  the  scientific  knowledge  of 
to-day  ? 

Brief  formulations  of  intricate  principles  are  often 
misleading,  incomplete,  or  fallacious ;  yet  the  tempta- 
tion to  formulate  the  new  principles  briefly  is  strong, 
because  their  intelligent  presentation  to  the  public  is  so 
vital.     Such  formulation  is  attempted  here. 

a.  Sources  of  Infectious  Diseases 

1.  Infectious  diseases  are  infectious  because  they  are 
due  to  the  growth,  in  the  body,  of  minute  animal  or 
vegetable  forms  (germs),  the  transmissibility  of  these 
germs  from  body  to  body  being  the  sole  explanation  why 
these  diseases  are  "  catching." 

2.  Wherever  in  the  body  the  germs  develop,  they 
leave  it  chiefly  in  the  discharges,  or  by  routes  of  the 
discharges,  of  the  nose  and  throat,  bladder,  or  bowel, 
i.e.,  from  the  main  orifices  of  the  body.2 

2  This  applies  to  all  the  ordinary  infectious  diseases  in  this 
zone.     Smallpox,   leprosy,   syphilis,   and  some  forms  of   tubercu- 


22  THE  NEW  PUBLIC  HEALTH 

3.  The  discharges  infect  another  person  practically 
only  when  that  person  takes  the  discharges,  in  some 
form,  into  the  mouth  or  nose,  except  in  trachoma  and 
the  venereal  diseases.3 

4.  Outside  the  body,  disease  germs  do  not  multiply 
in  nature,  except  perhaps  rarely,  and  very  temporarily, 
in  milk,  water,  or  similar  fluids.  In  general,  even 
typhoid  bacilli  disappear  from  water  supplies  within 
two  weeks,  without  evident  multiplication.  If  intro- 
duced into  milk,  most  infectious-disease  germs  die  out 
as  the  milk  becomes  acid,  generally  in  a  day  or  two. 
Infectious-disease  germs  are  rarely  found  in  garbage, 
and  they  quickly  die  out  if  deliberately  added.  Prac- 
tical modern  public  health  recognizes  therefore  that  the 
bulk  of  most  of  the  infectious  diseases  are  derived  di- 
rectly, or  almost  directly,  from  infected  persons,  not 
much  from  infected  things,  except  recently  infected 
water,  milk,  food,  and  flies.  The  danger  from  the 
general  environment  of  an  infected  person  is  therefore 
small.  The  things  in  his  neighborhood  need  little  con- 
sideration, except  those  very  immediately  about  him 
and  directly  infected  by  his  discharges,  such  as  bed- 
clothes,  personal  clothes,   towels,   eating  utensils,   and 

losis  are  transferable  from  skin  lesions  at  times.  Certain  tropi- 
cal diseases  are  transmitted  by  insects  tapping  the  blood-stream, 
etc.  Probably  all  infections  can  be  conveyed,  as  anthrax  and 
tetanus  usually  are,  directly  by  inoculation.  But  these  paths  are 
so  rare  as  to  be  negligible  in  ordinary  life  here. 

s  "  Infection  is  transmitted  from  an  orifice  of  the  inf ector  to 
an  orifice  of  the  infectee." 


INFECTIOUS  DISEASES  23 

other  material  objects  that  may  receive,  and  retain  for 
a  time,  fresh  moist  discharges.  If  attention  be  effi- 
ciently directed  to  infected  persons  and  their  discharges, 
the  general  surroundings  may  be  safely  ignored,  except 
in  the  rarest  instances.  Disinfection  of  premises  re- 
cently occupied  by  infectious  persons  (terminal  disin- 
fection), a  few  years  ago  considered  on  theoretical 
grounds  as  one  of  the  chief  weapons  against  disease, 
has,  on  practical  investigation  been  very  largely  aban- 
doned except  in  tuberculosis,  where  practical  investiga- 
tion shows  that  it  is  of  some  value,  if  the  premises  are 
to  be  used  within  a  month  or  so. 

b.  Routes  of  Infectious  Diseases 

5.  The  routes  by  which  the  discharges  of  the  sick 
person  pass  to  the  well  person  are  exactly  those  by 
which  the  same  discharges  pass  from  the  well  person 
to  the  well  person  in  ordinary  life ;  for  nose  and  mouth 
discharges  the  routes  are  mouth-spray,  and  sputum  con- 
veyed through  direct  contact  (as  in  kissing,  etc.),  and 
by  the  hands;  for  bowel  and  bladder  discharges,  the 
hands  chiefly;  and  for  all  discharges,  the  things  in- 
fected by  them  directly  or  through  the  hands,  especially 
those  things  which  then  go  to  the  mouth  or  touch  things 
which  go  to  the  mouth,  as  food,  water,  eating  utensils, 
towels,  pipes,  etc.,  etc.  Elies  also  furnish  an  effective 
route,  especially  from  feces  to  food.  Water  supplies 
are  peculiar,  because  bowel  and  bladder  discharges 
en  masse,  in  the  form  of  sewage,  often  enter  them  di- 


24  THE  NEW  PUBLIC  HEALTH 

rectly,  at  times  being  deliberately  poured  into  them 
from  city  sewers. 

6.  The  relative  importance  of  these  various  routes 
in  the  carriage  of  infection  varies  much.  The  amount 
and  freshness  of  the  discharges,  the  number  and  viru- 
lence of  the  germs  they  contain,  the  size  and  frequency 
of  the  dose,  and  the  number  of  susceptible  persons  who 
are  dosed,  must  always  be  considered.  Almost  all  the 
ordinary  infectious-disease  germs  die  out  quickly  on 
exposure  to  direct  sunlight,  and  fairly  rapidly  in  diffuse 
sunlight.  When  mucus,  feces,  and  urine  are  thor- 
oughly dried  on  furniture,  door-knobs,  etc.,  they  are 
not  readily  removed  again  without  moisture  and  fric- 
tion, and  when  so  removed  the  disease  germs  in  them 
are  likely  to  be  dead  or  greatly  reduced  in  recuperative 
power  because  of  the  drying.  Hence,  as  a  rule,  things 
succeed  in  conveying  infection  only  somewhat  directly 
from  the  infector  to  the  infectee,  and  practically  only 
during  the  limited  period  when  the  germs  are  still  fresh 
and  moist. 

c.  Control  of  Infectious  Diseases 

7.  These  new  principles  place  at  the  head  of  official 
public  health  activities,  the  search  for  and  supervision 
of  infected  persons,  and  the  control  of  the  infected 
discharges,  for  the  purpose  of  excluding  them  from 
mouths,  and  therefore  also  from  food  and  drink. 
Prompt  intelligent  disinfection  of  all  the  excreta  imme- 
diately after  their  discharge  from  the  body  (concurrent 


INFECTIOUS  DISEASES  25 

disinfection),  is  the  best  weapon  in  the  supervision  of 
infected  persons.  Isolation  of  the  infected  person  is 
the  next  best,  and  is  more  universally  practicable,  be- 
cause immediate  intelligent  disinfection  of  discharges 
can  rarely  be  secured  outside  of  the  very  best  hospitals 
for  contagious  disease.  The  search  for  and  supervision 
of  mild,  early,  convalescing,  unrecognized,  and  con- 
cealed cases  and  carriers,  as  well  as  of  frank  cases,  is 
necessarily  an  essential  item  in  the  scheme. 

8.  The  modern  public-health  department  requires  ex- 
perts, but  not  experts  in  municipal  house-keeping,  in 
street-cleaning,  garbage-disposal,  smoke-prevention,  etc. 
Its  experts  are  the  vital  statistician,  the  epidemiologist, 
the  laboratory  man,  and  the  sanitary  engineer,  the  lat- 
ter dealing  chiefly  with  the  broad  questions  of  water- 
supply  and  sewage-disposal. 


CHAPTER  IV 
WHY  DO  ANYTHING? 

It  has  been  well  said  that  the  day  of  the  priest  in 
public  health  has  passed:  to-day  is  the  day  of  the  doc- 
tor; but  I  think  that  to-morrow  will  be  the  day  of  the 
business  man,  the  man  of  large  affairs ;  and  it  is  to  him 
this  chapter  is  addressed. 

Until  such  time  as  poverty  is  abolished,  or  the  State 
takes  charge  of  children,  the  majority  of  the  women  of 
the  race  must  continue  to  rear  the  majority  of  the  chil- 
dren of  the  race  inadequately,  in  homes  too  small,  with- 
out facilities,  doing  for  them  somehow,  individually 
and  alone,  that  which  three  women  could  hardly  do  well, 
working  together. 

This  is  not  wholly  a  slum  problem  nor  is  it  a  problem 
of  the  rich.  Numerically  the  race  is  chiefly  middle 
class,  neither  rich  nor  extremely  poor,  judged  by  ordi- 
nary standards.  This  is  the  problem  of  the  family 
with  an  income  below  $3,000,  i.e.,  it  is  the  problem  of 
the  race  proper,  and  it  is  the  old  problem  of  the  pre- 
mosaic  Hebrew  —  how  to  make  bricks  without  straw  — 
alas,  often  without  knowing  how  to  make  bricks  at  all ! 

The  problem  as  a  whole  involves  food,  clothing, 
proper  physical  development,  morals,  education,  amuse- 

26 


WHY  DO  ANYTHING?  27 

ment,  discipline,  and  citizenship.  But  the  public  hy- 
gienist  has  as  yet  but  indirect  concern  with  these.  The 
public  hygienist  —  the  "  board  of  health  man  " —  as  yet 
concerns  himself  chiefly  and  by  general  expectation 
and  consent,  with  the  grosser,  more  imminent,  more 
spectacular,  more  immediately  tragic,  problems  of  dis- 
ease and  death,  and  chiefly  with  only  one  group  of 
these,  the  infectious  diseases.  However  much  in  ordi- 
nary life  overcrowding,  lack  of  facilities  and  overbur- 
dening of  mothers  may  render  unavailing  even  the  tears 
and  ageing,  the  back-ache,  heart-ache,  crooked  fingers 
and  wrinkled  faces  of  mothers  striving  for  their  young, 
ten  times  over  is  the  effect  of  these  seen  when  disease 
enters  the  family,  adding  its  burdens,  its  sorrows,  its 
disabilities  and  its  deaths. 

Once  more,  remember  this  is  not  in  the  slums  alone, 
nor,  numerically,  chiefly  there.  It  is  found  in  city  and 
country,  village  and  town,  everywhere,  the  overburden- 
ing of  mothers,  in  ordinary  life,  added  to  ten  times  over 
when  disease  springs  up. 

HOW    BIG    A   PKOBLEM    IS    IT  ? 

Call  the  population  of  the  United  States  100,000,000. 
Eemember  that,  sooner  or  later,  every  member  of  each 
generation  suffers  from  at  least  one  infectious  disease, 
often  from  two,  three  or  four,  and  it  is  clear  that  every 
generation  suffers  anywhere  from  100,000,000  to  300,- 
000,000  attacks  of  infections.  Each  generation  pays 
out  at  least  ten  billions  of  dollars  for  this  running  of 


28  THE  NEW  PUBLIC  HEALTH 

the  gauntlet,  not  to  speak  of  the  disability  and  death  of 
those  who  run  it  unsuccessfully.  Tuberculosis,  diph- 
theria, summer  diarrhea,  scarlet  fever,  measles,  typhoid 
fever,  whooping  cough,  chickenpox,  to  name  only  some 
of  those  best  known  to  the  laity,  how  much  sorrow,  dis- 
tress, poverty,  how  much  "  making  of  none  avail "  of 
mothers'  hopes  and  prayers  and  wearing  effort  have 
these  caused !  Yet  so  common  are  they  that  "  children's 
diseases  "  are  looked  upon  as  a  necessary  stage,  almost 
a  joke.  Indeed  some  people  deliberately  expose  their 
children  to  them,  "  to  have  it  over  with  " !  Yet  who 
bears  the  burden,  the  sleepless  nights,  the  extra  work, 
the  hope  deferred  ? 

Ninety-five  per  cent,  of  the  infectious  diseases  are 
nursed  at  home  by  mothers.  Next  to  the  children  them- 
selves the  ones  who  suffer  most  are  mothers. 

WHO    KEEPS    THE    INFECTIOUS    DISEASE    GOING? 

Once  more  the  answer  is  —  and  most  emphatically  — 
women  in  general,  but  chiefly  after  all  the  mother.  To 
be  sure  there  is  every  excuse  for  the  mother, —  over- 
work, overcrowding,  lack  of  facilities,  above  all  igno- 
rance and  misdirected  training,  "  misinformation  piled 
on  lack  of  any."  But  with  all  the  perfectly  good 
apologies  stated  and  all  the  excellent  good-will  and  ef- 
fort counted  in,  the  fact  itself  remains,  that  mothers 
propagate  and  keep  alive  and  spread  the  infectious  dis- 
eases of  children  more  than  any  other  one  body  of  peo- 
ple, and  that  while  conditions  remain  as  they  are  they 


WHY  DO  ANYTHING?  29 

must  learn  the  "  rules  of  the  game  "  and  follow  them, 
for  no  amount  of  coaching  or  effort  from  the  sidelines 
can  do  more  than  help. 

WHY   AND    HOW    AKE    WOMEN    RESPONSIBLE  ? 

Because  mothers  are  doing  the  work  —  women  in 
general,  but  chiefly  mothers.  The  farmer  is  responsible 
(apart  from  flood,  drought,  storm  or  other  "  acts  of 
God  ")  for  whatever  happens  to  the  crop  from  seed  to 
market.  Women  in  general  —  but  chiefly  mothers  — 
are  the  "  raisers  "  and  "  crop-handlers  "  of  the  largest, 
most  valuable,  most  expensive  and  most  difficult  crop 
in  the  country.  What  happens  to  this  crop  between 
birth  and  sixteen  years  of  age  is,  chiefly,  what  women 
do  to  it,  or  at  least  do  not  prevent.  For  the  first  5,000 
days  of  the  years  of  the  life  of  each  generation,  the  race 
is  fed,  dressed,  undressed,  washed,  combed,  cuddled, 
kissed,  praised,  blamed,  led,  driven,  coaxed,  taught, 
spanked,  bossed  and  otherwise  "  brought  up "  by 
women  —  women  mothers  at  home,  women  teachers  at 
school.  It  is  chiefly  during  this  time  of  tutelage  and 
supervision  by  women  that  children  receive  their  infec- 
tions ;  it  is  during  this  time  that  the  race  runs  its  gaunt- 
let, dances  its  little  dance  with  death  —  and  pays  ten 
billions  for  it. 

PRESENT    ATTEMPTS 

To  teach  women,  girls,  prospective  mothers,  that  they 
may  practice  in  their  households,  and  in  turn  teach 


30  THE  NEW  PUBLIC  HEALTH 

their  children  to  war  on  invisible  germ-foes  is  one  of 
the  functions  of  public  health  bacteriology.  Only  in 
the  public  schools  can  it  be  taught  with  emphasis,  weight 
and  uniformity  enough  to  impress  the  masses.  Only  if 
taught  in  the  grades  can  it  be  counted  upon  to  reach 
the  masses.  Less  than  1  per  cent,  of  the  population 
reach  the  university,  only  10  per  cent,  reach  the  high 
schools.  The  great  mass  of  the  mothers  of  the  coming 
generation,  of  the  whole  race,  the  mothers  of  more 
than  their  average  of  children,  are  receiving  grade 
school  education  only.     Need  more  be  said  ? 

The  infectious  diseases  in  general  radiate  from  and 
are  kept  going  by  women.  Women  must  learn  to  break 
up,  divert,  stop  in  some  manner  —  in  every  manner  — 
the  exchange  of  infected  discharges  amongst  children  at 
school  and  amidst  families  at  home  if  infectious  dis- 
eases are  to  be  abolished  or  abated  under  present  con- 
ditions. The  needful  information,  beliefs,  technique 
and  habits  cannot  be  had  or  established  except  by  study- 
ing the  basic  principles  of  public  health,  and  this  must 
be  taught  in  the  grades  of  the  public  schools  if  it  is  to 
reach  those  who  most  need  it. 

RADICAL  CHANGES  IN  SOCIAL  CONDITIONS  THE  KEAL 
SOLUTION 

If  (as  cannot  be)  every  girl  now  at  grade  school  could 
be  thoroughly  taught  all  that  a  trained  nurse  knows, 
theory  and  practice,  the  best  to  be  hoped  is  that,  be- 


WHY  DO  ANYTHING?  31 

coming  a  mother,  ten  to  twenty  years  hence,  she  may 
remember  enough  to  care  for,  if  she  have  the  facilities, 
the  first  case  of  infection  in  her  household  without  per- 
mitting its  spread  to  the  other  members  or  to  outsiders. 
Alas,  not  one-third  of  the  girls  will  remember,  not  one- 
tenth  will  have  the  facilities.  Above  all  what  shall  be 
done  in  that  intervening  ten  to  twenty  years  ?  Lectures, 
writings,  sermons,  appeals  to  mothers'  clubs,  university 
extensions,  moving  pictures,  all  the  publicity  that  can 
be  had  or  hoped  for,  will  not  suffice  to  teach  technique 
to  the  mothers  now  in  possession  of  the  coming  gener- 
ation. Nor  once  more,  if  it  taught  them,  would  it  pro- 
vide the  facilities  needed.  Economic  conditions  must 
change  and  change  specifically  to  aid  the  mother  if  we 
are  to  gain  at  all.  Also,  the  prevention  of  disease  must 
engage  the  serious  attention  of  governments  —  the  pre- 
vention of  disease,  not  the  talking  about  it  or  the  looking 
wise  over  it,  or  the  making  of  fine  addresses  on  it,  but 
preventing  it.  Such  prevention  may  include  a  tre- 
mendous organization  to  prevent  human  discharges  en- 
tering water  supplies,  milk  supplies,  food  supplies ;  must 
involve  watchfulness  of  hotels,  restaurants,  public  insti- 
tutions of  all  sorts  —  in  short,  of  all  public  alimentary 
utilities,  with  all  their  off-shoots  and  side  issues  wher- 
ever found.  It  must  include,  as  its  chief  and  most 
efficient  weapon,  the  finding  of  the  sources  of  infection, 
and  the  prevention  of  spread  of  infection  from  those 
sources.     This  is  peculiarly  a  governmental  function, 


32  THE  NEW  PUBLIC  HEALTH 

but  the  whole  must  be  cooperative.  The  government 
must  strike  at  the  sources  and  at  the  public  routes  of 
infection.  The  woman  must  strike  at  the  private 
routes.  The  man  must  support  both  methods  for  the 
sake  of  the  women  and  children. 


CHAPTER  V 
NON-INFECTIOUS  DISEASES 

SPECULATIONS 

The  previous  chapters  indicated  that  so  far  as  the 
infectious  diseases  are  concerned,  the  great  public- 
health  fallacy  of  the  nineteenth  century  consisted  in  the 
devotion  of  nearly  all  the  effort  to  man's  surroundings ; 
of  almost  none  at  all  to  man  himself.  We  know  now 
that  the  sources  of  infection  are  in  man ;  that  the  routes 
of  infection  are  the  routes  of  man's  discharges ;  and  that 
the  discharges  are  harmless  until  they  enter  man  again. 
It  is  true  that  when  the  infective  agents  reach  their  goal 
the  resistance  of  the  individual,  pitted  against  the  in- 
jurious powers  of  the  infective  agents,  decides  whether 
or  not  actual  disease  develops.  But  this  resistance  of 
the  individual  is  not  to  be  measured  by  his  surround- 
ings :  it  is  intrinsic  in  himself.  Alterations  of  intrinsic 
resistance  do,  of  course,  constantly  occur,  but  the  factors 
of  those  alterations  are  not,  as  a  rule,  to  be  readily  ascer- 
tained. We  think  that  great  extremes  of  malnutrition, 
temperature,  and  so  forth  may  "  depress  "  resistance. 
We  have  evidence  that  the  smoke  nuisance,  poor  venti- 
lation,  or   smells   from   slaughter-houses   do   not.     In 

33 


34  THE  KEW  PUBLIC  HEALTH 

brief,  granted  sufficient  exposure  to  infectious  disease, 
the  susceptible  individual  will  succumb,  though  he  live 
in  a  palace ;  the  immune  individual  will  escape,  though 
he  dwell  in  the  slums.1 

The  immunity  may  be  natural  —  born  with  the  in- 
dividual —  or  acquired,  but  this  is  beside  the  question. 
Far  more  practically  important  is  the  fact  that  the  inv 
munity,  natural  or  acquired,  is  specific.  The  individ- 
ual may  be  wholly  immune  to  one  disease  and  ultra- 
susceptible  to  another;  and  such  immunity  has  abso- 
lutely no  relation  to  physique,  robustness,  or  great 
vitality. 

The  outcome  of  the  environmental  doctrines  was  the 
binding  of  heavy  burdens  of  routine  administration  con- 
cerning surroundings  upon  health  departments.  Re- 
sults: garbage  disposal,  a  polytechnic  trade;  street- 
cleaning,  a  scientific  profession;  plumbing,  a  fine  art; 
and  the  supervision  of  infection,  a  dubious  and  usually 
a  temporary  "  job/'  too  often  left  to  utter  incompetents, 
or  to  those  who,  competent  enough,  are  unable  to  de- 
vote any  systematic  energy  and  very  little  time  to  it. 

•We  have  pursued  chimeras;  pursued  them  in  good 
faith  of  course,  but  chimeras  none  the  less. 

Suppose  now  that  we  admit  our  errors  and  give  to 

i  Tuberculosis  has  long  been  held  an  exception  to  this  rule. 
But  tuberculosis  was  also  held  as  (a)  non-infectious  and  (b) 
hereditary,  as  well  as  (c)  a  result  of  certain  surroundings.  We 
have  reversed  (a)  ;  we  have  reversed  (b)  ;  we  already  see  good 
reasons  to  modify   (c). 


NON-INFECTIOUS  DISEASES  35 

the  supervision  of  tuberculosis,2  which  we  do  under- 
stand, one-half  the  effort  we  have  given  to  the  super- 
vision of  ventilation,  which  we  are  only  beginning  to 
understand.  Suppose,  in  brief,  we  really  organize  and 
really  operate  a  real  machine  which  really  does  reduce, 
even  promises  to  abolish,  the  infectious  diseases.  Will 
it  be  a  surrender  of  our  birthrights  for  a  mess  of  pottage 
if  in  devoting  ourselves  to  the  suppression  of  disease  at 
first  hand,  we  forego  the  chasing  down  of  loose  paper 
on  the  streets  and  the  cleaning  up  of  rubbish  piles  on 
vacant  lots? 

PHYSICAL    PEEFECTION 

There  are  activities  contributing  to  health  beyond 
these  limits,  of  course;  and  some  of  them  are  things 
that  should  be  done  at  once  without  waiting  for  the 
complete  suppression  of  disease.  For  example,  every 
one  knows  that  the  bodily  welfare  of  mankind  does  not 
by  any  means  hinge  wholly  on  the  infectious  diseases. 
True,  the  abolition  of  these  diseases  means  also  the  abo- 
lition of  their  immediate  sequela?, —  sometimes,  as  in 
measles,  more  harmful  than  the  original  attack, —  and 
of  their  remote  sequela?,  the  permanently  injured  kid- 
ney and  the  permanently  weakened  lung.  But  even  so, 
a  full  half  of  our  medical  diseases  and  much  more  than 
half  of  our  surgical  diseases  would  still  remain;  more- 
over, merely  to  remove  disease  is  not  to  solve  the  whole 

2  To  say  nothing  of  syphilis,  gonorrhea,  summer  diarrhea,  and 
the  rest. 


36  THE  NEW  PUBLIC  HEALTH 

problem  of  securing  health  in  its  true  sense,  i.e.,  the 
highest  physical  efficiency  prolonged  for  the  greatest 
period  of  time. 

THE    GENERAL    PROBLEM 

The  chief  of  the  many  phases  of  disease  and  health 
are  best  shown  by  a  parable : 

As  a  new  automobile  is  accompanied  by  detailed  in- 
structions for  its  care  and  operation,  so  the  new  small 
citizen  should  be  accompanied  by  detailed  instructions 
for  his  care  and  operation  when  he,  a  delicate  and  com- 
plicated machine,  indeed,  first  appears  on  the  scene. 
This  knowledge  is  now  accumulated  by  his  parents 
chiefly  from  experience  (which,  remember,  are  his  ex- 
periences) or  by  picking  it  up  at  random  from  the 
neighbors  over  the  back-yard  fence.  To  secure  proper 
results,  the  instruction  of  the  mother  should  precede 
the  birth  of  the  child ;  and  the  proper  care  of  the  child 
involves  proper  care  of  the  mother  before  the  child  is 
born.  Prenatal  and  postnatal  care  are  almost  equally 
important  to  the  child,  and  the  former  is  peculiarly 
valuable  to  the  mother. 

Again :  As  a  new  automobile  is  searched  solicitously 
for  missing  or  defective  parts,  to  be  solicitously  and 
immediately  made  good  before  the  machine  is  sent  out 
to  run  against  competitors  on  the  highway,  so  the  new 
small  citizen  should  have  at  least  his  sight,  his  hearing, 
and  his  breathing  tested  before  he  begins  the  inevitable 
compulsory-education  race  against  all  comers  on  the  pub- 


NON-LNTECTIOUS  DISEASES  37 

lie  highway  of  the  public  schools.  Pre-school  supervi- 
sion will  soon  antedate  school  supervision.  Why  should 
the  child  suffer  for  its  first  five  years  defects  and  disa- 
bilities which  are  to  be  systematically  corrected  in  the 
sixth  ?  But  further :  As  the  most  initially  perfect  auto- 
mobile, most  skillfully  run,  will  yet,  as  time  goes  on, 
meet  accidents,  develop  internal  disruptions,  and  require 
repairs,  so  the  new  small  citizen,  despite  early  care  and 
early  correction  of  defects,  will  need  supervision  and 
repair  all  through  his  life,  at  school  and  afterwards. 

The  parable  must  end  here,  for  automobiles  present 
no  affections  analogous  to  infectious  diseases.  This 
very  fact,  however,  brings  out  more  clearly  the  crucial 
distinction  between  man  as  a  machine  and  man  as  a 
subject  of  infection.  As  a  machine,  he  may  be  efficient 
or  inefficient,  well  operated  or  ill  operated,  and  this  all 
quite  apart  from  the  existence  of  actual  defect  or  disa- 
bility. Contrariwise,  as  a  machine  he  may  suffer  initial 
defects  or  encounter  accidents  or  develop  internal  dis- 
ruptions, all  quite  apart  from  his  intrinsic  efficiency  or 
inefficiency  and  quite  apart  from  the  skill  with  which 
he  is  operated.  But  as  a  subject  of  infection,  man  is 
merely  a  soil  more  or  less  well  suited  to  the  growth  of 
certain  small  plants,  or  animals.3 

The  most  valuable  production  of  the  State  is  its  citi- 

3  The  fact  that  in  their  growth  these  little  invaders  from  with- 
out "  mess  up  the  works  "  and  make  trouble,  as  much  as  would 
disruptions  originating  wholly  from  within,  should  not  conceal 
the  radical  difference  between  the  sources  and  causes  of  defects, 


38  THE  NEW  PUBLIC  HEALTH 

zens;  and  the  State,  properly  conceived,  exists  only  to 
insure  life,  liberty,  and  the  pursuit  of  happiness  to 
them.  As  the  automobile  maker  insists,  for  his  own 
sake,  on  (a)  giving  instructions  and  (b)  correcting  de- 
fects; so  the  State  should,  for  its  own  sake,  (a)  instruct 
parents  and  (b)  remedy  children's  defects,  perhaps  also 
the  defects,  disabilities,  and  diseases  of  adults.  Cer- 
tainly, every  State  should  provide  at  least  — 

Education  for  parents  in  the  personal  hygiene  of 
children,  i.e.,  the  care  and  operation  of  their  children's 
bodies  as  machines ;  and  education  also  for  children  in 
the  physical  care  of  themselves. 

Supervision,  not  only  for  the  mere  detection,  but  also 
for  the  remedy,  of  initial  defects;  and  should  provide 
this  early  in  life,  the  earlier  the  better,  certainly  not 
later  than  the  beginning  of  the  compulsory-education 
course. 

Supervision  of  children,  at  least  throughout  school- 
life,  for  the  detection,  and  remedy,  of  such  defects,  disa- 
bilities, or  diseases  as  may  develop  during  that  period.4 

Finally,  the  supervision  of  infectious  diseases. 

disabilities,  and  non-infectious  diseases  on  the  one  hand,  and  of 
the  infectious  diseases  on  the  other.  The  former  may  develop 
in  any  mechanism;  the  latter  only  in  those  mechanisms  which 
furnish  a  suitable  soil  for  the  growth  of  the  extraneous  invaders. 
To  prevent  the  former  the  machine  must  be  well  built  and  of 
the  best  stock,  must  be  scrupulously  watched  for  defects,  must 
be  constantly  overhauled,  and  must  be  cared  for  and  operated 
in  the  most  skilful  manner.  To  prevent  the  latter  the  mere 
exclusion  of  the  invaders  is  all-sufficient. 

4  It  is  difficult  to  see  strictly  logical  reasons  why  such  super- 


NON-INFECTIOUS  DISEASES  39 

THE    PRESENT    SITUATION 

But  of  all  these  manifold  duties  of  the  State  to  the 
citizen,  only  one  of  those  which  can  be  clearly  shown 
to  bear  directly  on  his  bodily  welfare  has  been,  as  yet, 
fully  recognized  —  only  one  rests  on  definite  precedent, 
authorization  and  organization;  and  that  one  is  the 
supervision  of  infectious  diseases.  The  personal 
hygiene  of  the  citizen  (apart  from  the  infectious  dis- 
eases), and  the  remedy  (even,  until  lately,  the  mere 
detection)  of  his  defects,  disabilities,  or  non-infec- 
tious diseases,  have  been  regarded  (except  in  the  case 
of  the  pauper,  the  criminal,  or  the  insane)  as  of  little 
or  no  interest  to  any  one  but  himself.  And  this,  not- 
withstanding that  all  his  material  surroundings,  and  all 
his  relationships,  business  and  social,  have  been  of  ac- 
knowledged interest  to  the  State  from  time  immemorial. 
The  sanitation  of  environment  has  indeed  had  much 
attention;  usually  misdirected  and  almost  always  in- 
efficient, so  far  as  abolishing  infections  is  concerned. 

Why  this  negligence  of  the  individual,  with  excessive, 
misguided,  attention  to  his  surroundings?  First,  be- 
cause material  surroundings  are  property,  and  property 
has  always  had  precedence  over  persons  in  almost  every 
relation ;  second,  because,  in  the  special  relation  to  dis- 
ease, the  old  public  health  taught  that  the  citizen  was  a 

vision  should  end  with  school-life.  Germany  and  England  are 
experimenting  with  the  medical  supervision  of  adults.  Prenatal 
and  postnatal  supervision  are  already  United  States  Federal 
projects.     Minnesota  is  agitating  pre-school  supervision. 


40  THE  NEW  PUBLIC  HEALTH 

resultant  of  his  surroundings ;  and  even  in  the  infectious 
diseases  this  fallacy  ruled,  as  has  been  abundantly 
shown. 

Of  course,  the  State  is  concerned  with  man's  sur- 
roundings and  relationships.  It  must  consider,  plan 
for,  and  carry  out,  measures  for  his  comfort,  conven- 
ience, safety,  pleasure,  and  happiness,  as  well  as  merely 
for  his  health.  The  State  exists  to  do  for  its  citizens 
co-operatively,  hence  economically  and  authoritatively, 
all  those  necessary  things  which  the  individual  could  do 
only  by  great  sacrifices  or  perhaps  not  at  all.  But  to 
believe  that  the  securing  to  the  individual  of  every  pos- 
sible advantage  in  all  directions  is  the  duty  of  the  State, 
is  not  necessarily  to  believe  that  every  item  of  this 
program  should  be  carried  out  by  health  departments. 
To  hand  over  to  any  one  subdivision  of  the  government 
control  both  of  man  and  of  his  surroundings,  would  be 
to  hand  over  to  it  all  the  functions  of  government.  At 
once,  subdivision  of  these  activities  would  be  necessary 
and  these  subdivisions  would  necessarily  pattern  after 
those  of  present  governments.  Hence  such  a  "  re- 
adjustment "  would  merely  replace  existing  govern- 
ments, not  add  to  their  existing  efficiency. 

The  secret  of  successful  organization  is  the  parcelling 
out  along  natural  lines  of  all  the  different  activities 
which  are  to  be  co-ordinated  to  one  great  end.  It  is 
upon  the  shrewdness  with  which  the  subdivision  into 
logical  natural  groups  is  done  that  the  securing  of 
smoothly-running     co-ordination     depends.     Certainly, 


NON-INFECTIOUS  DISEASES  41 

one  most  logical  grand  division  of  any  government 
would  be  that  which  should  deal  with  man  apart  from 
his  surroundings;  and  one  most  logical  subdivision  of 
that  unit  should  deal  with  his  bodily  welfare  as  distinct 
from  his  mental,  moral,  or  other  welfare. 

Using  the  automobile  parable  for  guidance,  such  a 
"  Commission  on  Bodily  Welfare  "  should  deal  with  — 

Item  1.  The  education  of  every  citizen  in  personal 
hygiene. 

Item  2.  The  supervision  of  every  citizen  for  detec- 
tion of  defects,  disabilities,  and  disease. 

Item  3.  The  treatment  of  every  citizen  for  all  de- 
fects, disabilities,  and  diseases  detected. 

Item  4.  Finally,  that  function  to  which  the  automo- 
bile analogy  does  not  apply,  i.e.,  the  supervision  of  that 
small  group  of  citizens,  the  infectious  persons. 

How  closely  do  we  in  America  approximate  this 
ideal  ? 

Proper  education  of  every  citizen  in  personal  hygiene 
{apart  from  the  infectious  diseases)  is  scarcely  even 
foreshadowed  by  existing  efforts. 

Medical  supervision  {apart  from  the  pauper,  the 
criminal,  and  the  insane)  is  limited  to  a  small  portion 
only,  of  the  school  children  only,  in  a  few  cities  only; 
and  does  not  pretend  to  remedy  defects,  but  only  to  de- 
tect them.5 

s  About  two-thirds  of  the  children  of  America  live  and  attend 
school  in  rural  districts  where  medical  supervision  for  defects 
is  hardly  yet  more  than  contemplated. 


42  THE  NEW  PUBLIC  HEALTH 

Treatment  of  disease  (except  for  the  pauper,  the 
criminal,  and  the  insane)  is  a  matter  of  private  pur- 
chase or  of  private  philanthropy,  usually  the  private 
philanthropy  of  the  private  practicing  physician. 

The  supervision  of  infectious  persons  is  alone  really 
established,  authorized,  or  organized  as  a  recognized 
duty  of  the  State  throughout  America,  and  then  only 
so  far  as  the  protection  of  others  is  concerned.  We  have 
not  yet  reached  the  treatment  of  the  sick  even  though 
they  be  sick  of  infectious  disease. 

But  the  mechanism  for  even  the  function  of  prevent- 
ing infection,  although  it  is  actually  in  existence,  actu- 
ally organized,  actually  authorized,  actually  operating, 
and  has  behind  it  long  years  of  legal  precedence  and 
the  support  of  public  opinion,  is  sadly  under-manned, 
and  under-equipped, —  merely  a  skeleton. 

IMMEDIATE    POSSIBILITIES 

It  is  true  that  even  those  advanced  States  which  have 
organized,  in  part  or  in  whole,  the  above  outlined  oper- 
ations, organized  the  control  of  infectious  disease  far 
earlier  and  more  completely  than  they  organized  any  of 
the  others  notwithstanding  that  that  organization  is 
usually  inadequate  in  principle  and  inefficient  in  prac- 
tice. They  have  done  so  in  accordance  with  a  general 
rule,  which  governs  all  mankind,  namely,  that  of  doing 
first  the  simplest,  crudest,  and  most  obviously  necessary 
thing. 


NONINFECTIOUS  DISEASES  43 

But  it  is  also  a  matter  of  fact  that  the  supervision  of 
infectious  persons  differs  essentially  in  principles,  meth- 
ods, object,  extent  of  application,  and  destiny,  from  edu- 
cation in  personal  hygiene,  medical  supervision  for  de- 
fects, or  medical  treatment.  The  latter  are  obviously, 
directly  and  immediately  to  and  for  the  benefit  of 
the  individual  who  is  educated,  supervised,  or  treated. 
In  principle,  they  are  wise,  fore-sighted  and  economic 
additions  by  the  State  to  the  welfare  of  its  individual 
citizens.  But  the  former  is  not  to  the  benefit,  usually 
rather  to  the  temporary  detriment,  of  the  individual 
who  comes  under  its  operation.  Its  benefits  are  wholly 
to  others,  and  even  so  do  not  add  anything  to  their  wel- 
fare, but  merely  prevent  subtraction  from  it. 

The  methods  of  the  infectious-disease  supervisor  are 
necessarily  those  of  the  detective  and  the  policeman,  not 
those  of  the  educator  or  the  medical  supervisor.  The 
object  he  seeks  is  prevention,  not  construction  or  even 
repair.  He  does  not  deal  equally  with  every  citizen 
for  that  citizen's  good,  as  does  the  educator  or  the  phy- 
sician, but  he  ferrets  out  those  few  individuals  who 
must  be  restrained  for  the  good  of  the  others.  His  des- 
tiny is,  if  successful,  to  eliminate  the  only  reasons  for 
his  own  official  existence,  while  the  educator  and  the 
medical  supervisor  will  always  continue  to  find  in  each 
new  annual  crop  of  children  a  new  and  constantly  in- 
creasing field  for  their  services. 

In  brief,  the  first  three  activities  are,  like  boards  of 


44  THE  NEW  PUBLIC  HEALTH 

public  works,  constructional  in  essence.  Supervision  of 
infection  is,  like  the  work  of  fire  departments,  conserva- 
tive merely. 

But  although  we  may  accept  these  four  items  as  en- 
tirely proper  for  ultimate  realization,  we  must  acknowl- 
edge that  the  present  public-health  situation  cannot  be 
met  merely  by  handing  the  outline  over  to  boards  of 
health  or  health  departments  as  they  exist  to-day,  not- 
withstanding that  these  departments  constitute,  by  tra- 
dition and  precedent,  practice  and  organization,  that 
arm  of  the  government  to  which  have  been  assigned  the 
only  activities  of  the  State  in  relation  to  bodily  welfare 
so  far  seriously  or  widely  recognized. 

Health  departments  in  general  are  under-manned,  un- 
der-equipped, continually  distracted  with  futilities  like 
garbage  collection,  the  smoke  nuisance,  abolition  of  un- 
necessary noise  and  other  simple  police  matters  of  an 
administrative  character.  But  if  expanded,  their  dis- 
tractions eliminated,  and  their  faces  set  sternly  to  the 
reduction  of  disease  and  death,  they  could  not  at  once 
assume  all  the  items  of  this  program.     Why  ? 

The  treatment  of  every  citizen  for  all  defects,  disa- 
bilities and  diseases  we  may  dismiss  from  consideration 
at  present.  It  is  out  of  the  question  for  some  years  to 
come  in  this  country,  despite  the  development  reached 
in  England. 

For  the  education  of  every  citizen  in  personal  hy- 
giene the  basic  necessities, —  knowledge,  authority,  and 
organization, —  are  all  lacking.     Eor  the  supervision  of 


MW-IKFECTIOUS  DISEASES  45 

every  citizen  for  the  detection  (not  the  treatment)  of 
defects,  etc.,  knowledge,  authority,  and  equipment  can 
be  had,  it  is  true,  although  they  may  not  be  immediately 
available,  bnt  such  detection  of  defects  is  closely  bound 
up  with  treatment  and  should  not  be  divorced  from  it, 
except  as  a  method  of  demonstrating  the  need  for  treat- 
ment. 

Only  for  the  supervision  of  infectious  diseases  have 
we  now  all  three, —  knowledge,  authority  and  equip- 
ment, although  the  latter  merely  in  outline. 

EDUCATION" 

Furthermore,  it  is  true  that  the  education  of  every 
citizen  in  personal  hygiene,  cannot  be  carried  out  prop- 
erly (apart  from  the  prevention  of  certain  diseases)  by 
any  organization  at  the  present  time. 

Why?  Because  such  education  requires,  first,  the 
knowledge,  digestion,  and  formulation  of  the  facts  to  be 
taught ;  and,  second,  the  training  of  those  who  are  to  do 
the  teaching. 

But  the  best  of  us  do  not  know  personal  hygiene 
(apart  from  the  prevention  of  certain  diseases)  ;  that  is, 
we  do  not  know  how  to  care  for  and  operate  the  human 
body  as  a  machine.  What,  for  instance,  should  be 
taught  concerning  diet  when  Chittenden  and  Wiley  pro- 
mulgate exactly  opposite  views?  What  should  be 
taught  concerning  ventilation  when  the  whole  subject 
is  but  just  emerging  from  chaos?  What  should  be 
taught  concerning  clothing,  sleep,  exercise,  and  fatigue  ? 


46  THE  NEW  PUBLIC  HEALTH 

Our  physiologists  study  the  normal  body,  but  more 
in  relation  to  disease  than  to  health.  Our  vital  statis- 
ticians seek  the  factors  of  morbidity,  not  of  physical 
perfection.  Even  the  famous  Federal  "  poison  squad  " 
sought  to  determine  what  is  bad  for  people  to  eat,  not 
what  is  good  for  them.  All  of  these  things  are,  of 
course,  useful,  excellent,  even  essential  to  know;  but 
they  do  not  teach  us  personal  health,  they  teach  only 
the  avoidance  of  actual  disease. 

The  truth  is,  that,  as  regards  human  bodily  welfare, 
personal  hygiene  proper,  we  know,  well  enough  to  teach 
authoritatively,  but  one  factor,  that  is  the  disease  fac- 
tor. We  know  disease  because  we  have  studied  it.  We 
know,  it  is  true,  the  "  personal  hygiene  "  of  farm  ani- 
mals because  we  have  studied  the  "  personal  hygiene  " 
of  farm  animals,  at  a  cost  of  many  million  dollars  a 
year.  But  we  know  nothing  of  the  personal  hygiene  of 
human  citizens,  because  we  do  not  study  the  subject  at 
all,  except  the  hygiene  of  infants.  We  shall  never  know 
the  personal  hygiene  of  humans,  apart,  always,  from  the 
prevention  of  certain  diseases,  until  we  do  study  it  — 
until  we  put  as  much  time,  pains,  and  money  into  it  as 
any  agricultural  experimental  station  in  any  State  puts 
into  the  study  of  the  "  personal  hygiene  "  of  farm  ani- 
mals. True  it  is  a  far  more  difficult  subject,  but  that  is 
the  very  reason  why  it  requires  immensely  more  study 
and  experiment. 

We  recognize  that  the  study  of  animal  hygiene  re- 
quires care,  trained  investigators,  years  of  experiment. 


NON-INFECTIOUS  DISEASES  47 

Why  should  we  assume  that  the  current  dicta  of  those 
who  pose  as  preachers  of  hygiene  without  study  or  spe- 
cial knowledge  should  he  all  sufficient  in  the  case  of 
the  human  ? 

There  is,  however,  no  real  reason  why  health  depart- 
ments should  teach  personal  hygiene  at  all,  apart  from 
the  prevention  of  disease,  any  more  than  that  they 
should  teach  personal  morals  or  personal  finance. 
Health  departments  have  no  peculiar  knowledge  of  the 
one  any  more  than  of  the  others ;  and  if  they  had,  there 
are  professional  teachers  much  more  competent  and  pos- 
sessing far  greater  facilities  than  any  health  depart- 
ment. 

Education  concerning  even  infectious  diseases  is  not 
strictly  health-department  work.  This,  like  personal 
hygiene,  should  be  taught  seriously  and  systematically 
in  the  public  schools.  Ninety  per  cent,  of  the  popula- 
tion never  enter  high  schools,  and  only  1  per  cent, 
reach  the  university.  Whatever  of  personal  hygiene  or 
prevention  of  infection  the  citizen  should  know,  must 
be  taught  in  the  grades  or  miss  its  mark.  No  amount 
of  desultory  pamphleteering  or  lecturing  by  health  de- 
partments can  ever  take  the  place  of  properly  conducted 
grade  courses.  Unlike  courses  in  personal  hygiene, 
about  which  we  know  next  to  nothing,  courses  in  the 
prevention  of  infection  could  be  established  at  once, 
since  we  know  almost  all  about  it ;  but  it  is  no  part  of 
health-department  work  to  conduct  such  courses. 
Health  departments  are  police  bodies,  not  preachers  or 


48  THE  NEW  PUBLIC  HEALTH 

teachers.  They  may  well,  it  is  true,  educate  the  edu- 
cators. There  is  no  reason  why  they  should  educate 
the  public,  except  the  failure  of  the  professional  edu- 
cators to  do  so. 

MEDIC AL   SUPERVISION    OF    SCHOOLS 

Medical  supervision  of  school  children,  so  far  as  it 
deals  with  defects,  deals  with  non-transmissible  condi- 
tions. Medical  supervision,  so  far  as  it  deals  with  in- 
fection, deals  with  transmissible  conditions.  The  latter 
therefore  detects  links  in  the  chain  of  the  ramifying 
threads  of  infection  throughout  the  community, —  a 
ramification,  the  threads  of  which  unquestionably  should 
be  in  health-department  hands. 

But  medical  supervision  for  infectious  disease  in 
school  as  a  means  for  general  control  of  all  infections 
has  had  a  singularly  exaggerated  importance  attached  to 
it.  Only  one-half  of  the  State's  children  attend  school 
in  any  one  year,  and  even  the  school  child  passes  but 
one-ninth  of  each  year  in  school.  Were  health  depart- 
ments alert  in  their  familiarity  with,  and  efficient  in 
their  control  of,  the  ramifications  of  the  chains  of  in- 
fection outside  of  the  schools,  they  would  locate  and 
supervise  the  infective  child  before,  not  after,  he  had 
infected  school  children;  before,  not  after,  the  medical 
supervisors  for  defects  discovered  him  in  the  class-room. 
This  would  be  accomplished  incidentally  to  the  control 
of  infectious  diseases  amongst  children  below  and  above 
school  age,  as  well  as  in  adults. 


NON-INFECTIOUS  DISEASES  49 

The  fact  is  that  medical  supervision  for  defects  need 
never  encounter  infection  in  that  one-fourth  of  the  total 
population  which  is  contained  in  the  schools,  if  health 
departments  did  their  work  properly  in  the  other  three- 
fourths  which  is  outside  of  the  schools.  But  this  fact 
carries,  alas,  no  guarantee  that  infective  children  will 
not,  for  a  long  time  to  come,  occupy  a  share  of  the  medi- 
cal school  supervisors'  attention  because,  for  a  long  time 
to  come,  health  departments  will  not  effectively  con- 
trol infection,  inside  or  outside  of  schools,  unless  pres- 
ent methods  are  radically  readjusted  and  expanded. 
Especially  will  this  be  true  in  rural  districts  where 
nearly  two-thirds  of  the  children  secure  their  education 
and  where  health-department  organization  and  equip- 
ment is,  practically  speaking,  non-existent. 

Hence,  whatever  may  be  our  individual  views  with 
regard  to  the  ultimate  relation  of  medical  school-super- 
vision for  defects  to  supervision  of  infectious  persons, 
we  need  not  blind  ourselves  to  the  fact  that  ideal  condi- 
tions are  far  in  the  future,  and  that  immediate  necessi- 
ties call  for  immediate  adjustments  which  may  be  tem- 
porary or  not,  depending  on  future  developments. 

Medical  supervision  for  defects  and  medical  super- 
vision for  infection  are  now,  and  for  some  time  to  come 
must  remain,  so  interdependent  that  the  closest  co-oper- 
ation, even,  in  the  rural  districts,  amalgamation,  will  be 
necessary.  Such  amalgamation  should  be  under  health 
departments,  wherever  that  is  possible,  rather  than 
under  school  boards. 


50  THE  NEW  PUBLIC  HEALTH 

First,  because  school  boards  have  no  authority  through 
tradition,  from  precedence  or  by  law,  as  have  health  de- 
partments to  follow,  outside  of  the  schools,  the  ramifica- 
tions of  infection  of  which  the  infective  child  in  the 
school  constitutes  but  one  link,  nor  even  to  follow  that 
one  link  back  to  its  home. 

Second,  because  school  boards  have  no  information  or 
authority  concerning  the  full  half  of  the  children  who 
are  not  of  school  age  nor  concerning  any  adult  except 
those  directly  connected  with  the  schools. 

Finally,  amalgamation  in  the  rural  districts  is  essen- 
tial for  one  great  reason,  if  for  no  other,  and  this  reason 
is  that  if  we  do  not  combine  both  functions  in  one,  in  the 
rural  districts,  we  shall  not  secure  either  function  there 
at  all. 

SUMMARY 

Non-infectious  diseases,  disabilities,  and  defects  con- 
stitute a  field  for  governmental  attention  as  great  as  or 
greater  than  do  the  infectious  diseases. 

There  are  no  theoretical  reasons  why  governments 
should  not  concern  themselves  with  the  greater  (the  non- 
infectious group),  as  well  as  with  the  lesser  (the  infec- 
tious group). 

Public-health  activities  in  their  very  broadest  con- 
ception would  include  all  the  functions  of  government, 
since  there  is  nothing  of  interest  to  man,  from  high 
finance  to  municipal  playgrounds,  which  has  not  some 
relation  to  health. 


NON-INFECTIOUS  DISEASES  51 

But  an  administrative  system  so  vast  as  to  control  all 
human  activities  related  to  health  would  merely  re- 
place the  government,  and  would  itself  be  necessarily 
subdivided,  much  as  existing  governments  are  now. 

It  is  not  difficult  to  outline  a  logical  program  for  one 
branch  of  any  government,  a  branch  which  should  deal 
with  the  bodily  welfare  of  man  and  include  hygienic 
education,  medical  supervision,  medical  treatment,  and 
the  suppression  of  infectious  diseases. 

But  there  are  many  practical,  as  well  as  theoretical, 
reasons  why  health  departments  will  not,  indeed  cannot, 
proceed  at  once  to  put  this  program  into  execution. 
Concerning  education  in  personal  hygiene,  apart  from 
the  infectious  diseases,  agreement  as  to  the  basic  facts 
to  be  taught  has  yet  to  be  reached.  As  to  the  second 
and  third  items,  organization,  broad  precedent,  and 
broad  authority  are  all  lacking. 

Concerning  the  infectious  diseases,  and  concerning 
them  only,  are  the  paths  clear  and  the  duties  plain. 

The  "  instant  need  of  things  "  is  to  do  faithfully  and 
well  that  one  duty  which  we  fully  understand,  the  only 
one  for  which  organization,  authority,  tradition,  prece- 
dent, and  the  support  of  public  opinion  are  already  in 
our  hands,  i.e.,  the  abolition  of  infectious  diseases.  To 
this  end,  the  embryonic  beginnings  of  the  medical  super- 
vision of  every  citizen  —  that  is,  medical  school-super- 
vision —  should  lend  its  aid,  especially  in  the  rural  dis- 
tricts. 

But  until  we  have  accomplished  this  —  the  simplest, 


52  THE  NEW  PUBLIC  HEALTH 

easiest,  crudest  of  our  obvious  aud  recognized  duties, 
that  one  which  lies  right  at  our  finger-tips  —  we  cannot 
very  well  ask  that  the  Nation  should  hand  over  to  health 
departments  all  its  great  problems  of  life,  death,  health, 
and  national  development. 

To  achieve  the  abolition  of  infection  we  must  strip 
for  action,  discard  all  useless  armor  and  antiquated 
weapons,  cease  desultory  bombardment  at  leisurely  long 
range  of  the  enemy's  outlying  domains,  and  personally 
seek,  with  well-shortened  weapons,  the  enemy  himself 
(infection)  in  his  real  stronghold  (the  infective  person). 


CHAPTEK  VI 
EDUCATIONAL  MECHANISM 

The  teaching  of  these  new  principles  of  Public 
Health  must  begin  with  the  teaching  of  the  teachers. 
Until  our  leading  public  health  men,  physicians,  physi- 
ologists, and  clergy  acknowledge  these  teachings  and 
give  them  their  endorsement  the  old  misleading  state- 
ments, household  traditions,  worn-out  dicta,  now  consti- 
tuting the  baseless  platitudes  of  most  public  health  be- 
liefs, will  remain  false  beacon  lights  leading  nowhere. 

It  is  time  for  all  such  leaders  to  awake  and  ask  them- 
selves whence  these  teachings  came.  They  are  not  in 
our  books ;  they  are  not  propagated  by  our  leading  men 
of  science.  For  instance  no  student  of  the  subject  has 
said  a  word  to  make  any  one  believe  that  young  children 
die  of  infections  in  less  proportions  than  older  children 
do,  but  quite  the  contrary.  Yet  in  the  face  of  all  the 
books,  all  studies  on  the  subject,  all  figures  of  statistics 
ever  gathered,  the  medical  profession  itself  in  large  pro- 
portions repeats  the  worn  out  sophistry :  let  them  have  it 
early  and  get  it  over  —  youth  is  the  safest  time;  just 
as  it  repeats  many  another  misconception  not  less  ma- 
lignant in  its  evil  leading.  That  typhoid  fever  is  a  filth 
disease  and  due  to  general  dirt,  has  been  exploded  for 

53 


54  THE  NEW  PUBLIC  HEALTH 

many  years,  yet  we  hear  this  statement  made  on  every 
hand.  Typhoid  fever  is  not  by  any  means  carried  by 
water  only,  yet  this  bit  of  knowledge  seems  still  un- 
known to  many  leaders,  even  public  health  men.  That 
the  weak  contract  disease  more  than  the  strong  one  hears 
proclaimed  from  every  pulpit,  clerical  or  lay  —  but 
asked  for  their  authority  these  proclaimers  quote  only 
the  word  of  mouth  of  some  physician  who  in  turn  can 
find  only  untraced  tradition  as  his  authority. 

Once  leaders  are  agreed,  the  next  most  necessary  step 
will  be  a  revision  of  the  teachings  in  Normal  Schools; 
and  this  necessitates  the  preparation  of  books  on  hygiene 
that  will  place  in  proper  perspective  all  the  real  health 
measures  that  we  have  and  show  just  what  each  one 
will  do.  The  public  must  be  trusted  with  the  facts. 
The  timid  soul  holds  back  the  truth  that  bathing  does 
not  prevent  disease,  that  lack  of  bathing  does  not  end 
in  sudden  death,  because  forsooth  he  fears  the  children 
may  come  dirty  to  his  school !  He  forgets  that  the  chil- 
dren often  come  dirty  now,  in  spite  of  all  his  teaching ; 
true  many  others  are  clean,  but  both  escape  disease  or 
suffer  from  it  quite  irrespective  of  the  number  of  their 
baths.  They  who  bathe  from  fear  of  death  are  few, 
and  we  must  reach  clean  bodies  by  some  other  route 
than  bogies  held  up  with  orotund  words,  bogies  whose 
pumpkin  heads  and  candle-sputtered  light  the  listeners 
sense  although  they  may  not  see  the  mechanism.  Hon- 
esty in  teaching  is  as  necessary  in  our  public  health  as 
in  our  mathematics  or  geography. 


EDUCATIONAL  MECHANISM  55 

Let  us  face  frankly  this ;  about  the  body-care  we  know 
few  facts  of  practical  application  to  our  everyday  life 
that  are  really  hygienic,  not  merely  aesthetic.  We  know 
of  course  we  should  not  be,  for  high  efficiency,  too  hot, 
too  cold,  too  wet,  too  dry,  too  hungry  or  too  full.  We 
should  not  sleep  too  long,  nor  sleep  too  little,  work  too 
hard,  or  loaf,  and  so  on ;  but  to  say  what  is  too  much  or 
too  little  for  any  given  person,  especially  to  lay  down 
the  golden  mean,  is  something  no  one  knows.  The  in- 
dividual variations  in  individuals  are  very  great ;  what 
is  too  hard  work  for  one  will  scarcely  stir  the  blood  of 
another.  "  What  is  meat  for  one  is  another's  poison." 
These  variations  are  partly  inherent;  the  exposure  to 
cold  which  would  be  disastrous  for  the  negro  or  even  the 
white  man  is  likely  to  suit  the  Inuit  exactly;  but  also 
previous  training  and  experience  affect  exercise  and 
sleep  and  diet,  etc.,  by  the  establishment  of  compensa- 
tions, for  the  range  of  adaptation  of  the  body  to  vari- 
ations is  very  great:  finally  it  seems  probable  that  the 
following  out  of  any  exact  "  ideal "  regimen  would  be 
in  itself  far  from  ideal,  for  it  would  do  away  with  those 
very  variations  which,  by  cultivating  compensations, 
maintain  the  body  in  its  best  state  of  general  efficiency 
to  meet  the  inevitable  physiological  emergencies  of  daily 
life. 

That  such  an  ideal  regimen  would  be  far  from  ideal 
because  of  its  utter  impracticability  for  the  great  mass 
of  the  race  seems  seldom  to  occur  to  those  who  advocate 
the  search  for  it.     The  great  mass  of  the  work-a-c 


56  THE  NEW  PUBLIC  HEALTH 

world  must  now  and  for  long  generations  yet  to  come 
eat,  sleep,  work,  etc.,  not  as  they  would  but  as  they 
can. 

It  is  of  course  true  that  the  excesses  and  the  depriva- 
tions from  which  so  many  people  suffer  are  so  extreme 
as  to  be  obviously  harmful  often  even  to  themselves  and 
quite  obviously  so  to  those  acquainted  with  any  sort  of 
good  bodily  condition.  But  these  extremes  are  often 
either  results  of  poverty  or,  curiously  enough,  results  of 
choice  upon  the  part  of  those  concerned,  particularly  in 
sleep,  diet,  and  work.  The  race  as  a  whole  does  not 
desire  efficiency  in  practice,  but  chiefly  excitement  or 
amusement.  To  these  ends,  substituted  in  many  minds 
for  the  more  worthy  pursuit  of  happiness,  much  of  the 
lack  of  hygiene  exemplified  by  the  excesses  and  the 
deprivations  may  be  traced,  rather  than  to  real  neces- 
sity. 

The  great  preacher  urging  on  his  flock  the  highest 
ideals,  often  breaks  down  himself  from  over-strain,  thus 
failing  to  practice  what  he  preaches  every  day.  The 
physician,  the  lawyer,  the  teacher,  often  neglectfully  or 
deliberately  break  the  simplest  rules  prescribing  the 
most  liberal  limits  for  bodily  success. 

Hence  the  educational  campaign  for  hygiene,  i.e.,  for 
bodily  efficiency,  must  be  antedated  by  or  combined  with 
a  general  reconstruction  of  ideals  not  based  on  mere 
intensity,  but  on  all-round  development ;  and  these  must 
be  so  shaped  that  every  one  may  have  within  his  ready 
grasp  the  opportunities  for  such  a  life  that  the  extremes 


EDUCATIONAL  MECHANISE  57 

are  not  forced  on  him  by  circumstances  taking  their 
roots  in  the  foundations  of  society  itself. 

Hygiene  then  in  its  practical  application  to  the  world 
at  large  is  something  still  far  in  the  future,  requiring 
as  a  rule  the  reconstruction  of  individual  but  far  more 
of  communal  life.  As  yet  we  do  not  so  study  the  body 
of  the  human  in  our  physiology  as  to  determine  what 
are  the  ideal  conditions.  We  are  beginning  to  do  so; 
and  for  our  public  institutions  some  sort  of  rules  of 
thumb  relating  to  clothing,  exercise,  and  diet  are  traced 
out  to  meet  the  average  wants.  But  who  that  knows  our 
institutions  would  dare  claim  that  the  conduct  of  them 
really  meets  the  bodily  demands  of  all  their  inmates  or 
brings  them  to  the  highest  point  of  physical  efficiency  ? 
Too  often,  outside  of  armies,  this  is  not  by  any  means 
the  ideal  held  in  mind.  In  most  institutions  keeping 
down  expense  is  the  chief  object ;  in  our  industrial  oper- 
ations the  commercial  output  is  the  goal,  not  the  condi- 
tion of  the  factory  hands.  True  it  is  that  public  health, 
in  the  division  which  deals  with  hygiene  (efficiency  with 
comfort,  and  long  life  for  all),  must  rest  upon  the  at- 
tainment of  the  ideals  sought  by  many  sociological  move- 
ments for  the  mental  and  moral  recasting  of  the  race. 
Xo  movement  which  has  for  an  object  the  proper  under- 
standing of  man  or  of  any  of  his  relations  to  the  world 
can  fail  to  be  helpful  in  some  way  to  this  end. 

But  when  we  turn  to  the  second  great  item  of  public 
health,  the  prevention  of  disease,  we  find  a  different 
situation.     True,  as  has  been  already  explained,  proper 


58  THE  NEW  PUBLIC  HEALTH 

hygiene  necessarily  eliminates  certain  diseases  which 
arise  from  improper  living,  accidents,  the  effects  of 
monotonous  repetitions  of  the  same  movements,  or  the 
monotonous  maintenance  of  the  same  positions ;  certain 
non-living  poisons;  and  the  internal  disruptions  and 
disabilities  due  to  excesses  and  deprivations.  The  edu- 
cation needed  to  eliminate  these  must  in  itself  be 
specific ;  although  the  realization  of  their  abolition  must 
be  the  result  of  improvements  in  general  social  and 
trade  conditions.  Accidents  occur  amongst  millionaires 
as  well  as  amongst  factory  hands ;  lead  poisoning,  phos- 
phorous poisoning,  alcoholism,  etc.,  depend  after  all 
upon  taking  those  poisons  into  the  body.  They  cannot 
occur  under  the  worst  sociological  conditions,  not  even 
in  the  utter  barbarism  of  the  Central  African  village, 
unless  those  poisons  enter  into  the  system.  The  most 
important  of  all  the  preventable  diseases,  the  infectious, 
are  likewise  due  to  specific  poisons;  but  poisons  alive, 
living  and  breeding  in  human  bodies.  No  sociological 
advances,  no  moral  developments,  no  improvement  in 
living  or  in  the  relations  of  man  to  man,  no  raising  of 
the  standards  of  surroundings,  no  highest  care  of  the 
body  or  attention  to  its  efficiency  can  evade  these  unless 
the  specific  germ  is  evaded;  which  means  evading  the 
contact  of  uninfected  man  with  infected  man.  But  all 
sociological,  moral  and  mental  advance  tend  to  cultivate 
contact,  to  bring  all  classes  of  people  closer  together,  to 
knit  the  social  fabric  into  more  interdependent  and 
mutually  helpful  structures. 


EDUCATIONAL  MECHANISM  59 

Industrial  advances  gathering  together  larger  and 
larger  groups  of  people  engaged  in  the  same  enterprises 
result  in  more  and  more  social  intercourse  in  masses, 
especially  well  knit  if  moral  and  mental  development  of 
the  groups  is  sought.  The  public  schools  tend  to  more 
and  more  getting  together,  to  wider  interests,  to  the 
closer  affiliation  of  each  individual  with  every  other. 
Improved  transportation,  the  essential  to  national 
growth,  has  as  its  avowed  object  the  extension  of  contact 
of  one  with  another.  The  specific  poisons  of  the  spe- 
cific infectious  diseases  are  transmitted  by  this  contact. 
So  long  as  such  contact  continues,  much  more  as  it  is 
extended,  these  diseases  will  be  more  and  more  widely 
spread,  unless  the  specific  poisons  themselves,  which 
are  bred  in  human  bodies  and  transferred  in  human  dis- 
charges, can  be  themselves  eliminated.  The  hope  that 
the  remodeling  of  human  conduct,  the  education  of  the 
race  to  protect  each  other  by  the  elimination  of  the  ex- 
change of  these  discharges,  is  negatived  by  the  character 
of  the  exchange.  True  in  the  illicit  venereal  diseases 
the  form  of  contact  most  often  operative  to  propagate 
these  diseases  is  a  form  of  contact  which  is  not  essential 
to  ordinary  business  or  social  relations  and  can  be  volun- 
tarily ended.  But  the  moral  and  mental  development 
of  the  race  as  a  whole  to  the  point  where  this  form  of 
contact  is  eliminated  cannot  be  hoped  for  in  many 
years  to  come.  Like  alcoholism,  venereal  diseases  will 
be  contracted  so  long  as  the  specific  cause  is  to  be  had. 
In  the  "  children's  diseases,"  each  new  crop  of  children, 


60  THE  NEW  PUBLIC  HEALTH 

each  theoretically  amenable  to  training  in  self  protec- 
tion, contract  these  diseases  before  they  can  be  trained. 
Finally  the  technique  of  self  protection  and  of  protec- 
tion of  others  through  the  skillful  limitation  of  the 
spread  of  discharges  is  a  technique  acquirable  only 
after  months  of  rigid  training  by  those  devoted  to  the 
especial  studies  and  work  connected  with  it,  in  con- 
tagious hospitals,  so  that  even  highly  trained  experts 
dealing  with  infections  contract  them  at  times;  and 
when  themselves  infected  find  it  immensely  difficult  to 
protect  others  unless  they  too  are  trained.  Education 
directed  to  the  vanquishment  of  these  diseases  must 
therefore  be  education  pointing  out  the  specific  sources, 
the  impossibility  of  the  protection  against  them  by  any 
form  of  conduct  practicable  in  ordinary  life,  and  the 
necessity  for  the  elimination  of  the  infection  itself. 
This  elimination  means  the  search  for  and  the  restric- 
tion of  the  small  number  of  infected  persons  existing  at 
any  given  time,  with  the  object  of  eliminating  infection 
from  them  and  restoring  them  to  the  communal  life 
when  free  of  danger  to  the  community.  The  mechan- 
isms needed  to  discover  these  infected  persons,  a  general 
agreement  that  their  temporary  segregation  is  essential, 
a  mutual  helpfulness  in  discovering  them  and  in  assist- 
ing those  charged  with  that  duty,  all  these  can  be  se- 
cured by  education.  But  the  actual  doing  of  the  work 
itself  must  rest  in  the  hands  of  experts  armed  with 
full  authority,  pursuing  their  ends  with  quiet  persist- 
ence and  largely  without  spectacular  show  or  noise. 


EDUCATIONAL  MECHANISM  61 

To  the  extent  to  which  the  discovery  and  temporary 
segregation  of  the  infected  may  remove  these  infected 
individuals  from  the  communal  life,  such  operations 
will  benefit  the  communal  life;  and  the  provision  for 
the  care  and  maintenance  of  those  thus  segregated  and 
of  those  dependant  on  them  must  be  a  communal 
charge.  But  the  community  would  gain  so  immensely 
in  efficiency  and  comfort  and  long  life  by  the  segrega- 
tion of  the  infected,  because  of  the  thus  obtained  elimi- 
nation of  disease  and  death  from  the  uninfected  that 
the  expense  of  suffering,  disease,  and  death,  existing 
now,  might  well  be  thus  diverted  to  the  purpose  of  es- 
caping both. 

SUMMAKY 

The  education  of  the  public  in  personal  hygiene,  the 
development  and  efficiency  of  the  body,  must,  like  all 
other  effective  education,  be  carried  out  through  the 
public  schools;  although  immense  service  may  be  done 
by  educational  propaganda  in  the  magazines  and  news- 
papers, which  now  form  the  postgraduate  schools  of  the 
race. 

The  elimination  of  those  diseases  which  depend  upon 
the  physical  surroundings  must  be  a  matter  of  specific 
training  of  those  who  come  in  contact  with  those  spe- 
cific surroundings  in  such  sociological  improvements  as 
may  eliminate  their  existence.  In  the  infectious  dis- 
eases the  poisons  are  not  definite  visible  labeled  things 
but,  to  the  ordinary  citizen,  invisible  and  undetectable. 


62  THE  NEW  PUBLIC  HEALTH 

They  are  not  limited  to  certain  kinds  or  forms  of  sur- 
roundings but  exist  in  human  beings  themselves.  They 
can  be  found  only  by  specific  methods  and  the  condi- 
tions under  which  they  are  transmitted  cannot  be  so 
sufficiently  altered  in  practical  everyday  life  as  to  re- 
strict their  transmission  by  private  effort.  The  infec- 
tious diseases  therefore  are  peculiarly  matters  for  di- 
rect Governmental  control ;  and  the  Governmental  meas- 
ures undertaken  must  be  planned  and  carried  out,  not 
merely  to  hold  them  in  abeyance,  but  to  secure  their 
absolute  abolition. 


CHAPTER  VII 
THE  OLD  PEACTICE  AND  THE  NEW 

EPIDEMIOLOGY 

The  previous  chapters  were  designed  to  clear  the 
way  for  the  constructive  program  which  the  following 
chapters  seek  to  set  forth. 

The  conclusion  so  far  reached  is  that  the  chief  imme- 
diate duty  of  official  public  health  is  the  abolition  of  all 
the  infectious  diseases.  Eor  this  great  enterprise,  both 
scientific  principles  and  scientific  practice  are  essential. 
The  new  public  health  principles  have  been  outlined; 
the  new  public  health  practice  remains  to  be  explained. 

Public  health  practice  in  handling  infectious  dis- 
eases may  be  traced  through  three  distinct  eras:  past, 
present,  and  future. 

Past,  or  era  of  "  general  sanitation/' —  The  practice 
followed  energetically  in  epidemics,  spasmodically  and 
perfunctorily  at  other  times,  consisted  in  a  strenuous 
campaign  of  "  general  cleaning  up  "  ;  an  orgy  of  sweep- 
ing, burning,  scrubbing;  an  ecstasy  of  dirt-destruction, 
individual,  household,  municipal.1 

i  The  reader  is  begged,  pleaded  with,  besought,  not  to  repeat  at 
this  point  the  wearisome  old  gibe —    Then  you  want  us  to  lire 

63 


64  THE  NEW  PUBLIC  HEALTH 

This  "  general  sanitation  "  was  a  true  old-style  shot- 
gun prescription,  used  discriminatory  for  any  out- 
break of  any  disease.  No  distinction  of  sources  from 
routes  of  infection  was  made ;  indeed,  that  a  distinction 
existed  was  hardly  recognized,  and,  looking  back,  it 
sometimes  seems  that  even  the  most  obvious  relations  of 
cause  and  effect  often  were  ignored. 

Present,  or  era  of  "  specific  sanitation/' —  The  best 
practice  now  is  deliberately  to  analyze  the  particular 
outbreak  of  the  particular  disease  concerned;  speedily 
to  determine  thus  the  exact  route  of  infection  actually 
responsible ;  and  promptly  to  abolish  or  block  that  route. 

Future,  or  era  of  "  supervision  of  sources/' —  The 
practice,  so  far  as  it  is  possible  to  forecast  it,  will  be  the 
location  and  supervision  of  the  sources  of  infection  (in- 
fected persons)  before,  not  after,  they  gain  access  to 
routes;  thus  in  time  eliminating  infectious  diseases  en- 
tirely. 

like  pigs?  If  not,  why  do  you  condemn  "general  sanitation"? 
We  do  not  condemn  "  general  sanitation,"  or  cleanliness,  or 
order,  or  decency.  We  simply  present  the  scientific  fact  that 
these  things  do  not  greatly  prevent,  nor  does  their  absence  pro- 
duce, infectious  diseases.  They  have  a  thousand  advantages,  but 
not  this  one.  Honesty  does  not  protect  against  lightning;  yet 
this  fact  cannot  prevent  any  truly  honest  man  from  remaining 
honest,  nor  does  its  statement  in  the  least  detract  from  the  true 
virtues  of  honesty.  And  so  with  "general  sanitation."  It  is 
specific,  not  "  general,"  cleanliness  that  prevents  infection. 
Specific  cleanliness  is  that  directed,  not  broadly  and  blindfold 
against  all  "  dirt,"  but  scientifically  and  efficiently  against  the 
one  "dirt"   (infected  matter)   that  produces  disease. 


THE  OLD  PRACTICE  AND  THE  NEW      65 

It  will  be  noted  that  public  health  practice  as  thus 
outlined,  past,  present,  and  future,  forms  a  definitely 
developing  mechanism,  concentrating  itself  by  degrees 
from  the  general  to  the  particular,  from  the  surround- 
ings to  the  individual,  from  (a)  the  random  applica- 
tion of  blanket  measures,  through  (b)  a  specific  detec- 
tion and  a  specific  correction  of  a  specific  bad  condi- 
tion, to  (c)  the  actual  forestalling  of  the  development 
of  such  conditions  at  all. 

COMPARATIVE    METHODS 

To  make  clear  this  most  important  matter  of  public 
health  practice,  illustrations  follow,  exhibiting  the  pub- 
lic health  practice  of  the  different  eras  as  each  would 
operate  in  the  face  of  a  typhoid  fever  epidemic ;  typhoid 
being  selected  because  the  control  of  this  one  disease 
alone  calls  for  almost  every  modern  public  health  prin- 
ciple, and,  in  some  form,  every  modern  public  health 
practice. 

The  end  sought  was,  is,  and  always  will  be,  the  same, 
—  to  stop  the  spread  of  the  disease. 

But  the  methods  of  the  different  eras  contrast  widely. 

In  the  past  era  of  "  general  sanitation/'  a  typhoid 
epidemic  was  met  by  a  vigorous  attack  on  dirt,  damp 
cellars,  dust,  disorder;  on  garbage,  manure,  dead  ani- 
mals, weeds,  defective  plumbing,  and  stagnant  pools; 
cobwebs  were  cleared  away;  windows  were  opened  to 
"  let  in  the  blessed  sunshine " ;  preachers  preached 
cleanliness;    teachers   taught    bathing;    health    officers 


66  THE  NEW  PUBLIC  HEALTH 

limed  back  alleys  and  whitewashed  outhouses.  Human 
nature  demanded  "  action/'  and  "  action,"  of  a  kind, 
was  supplied.  As  a  rule,  the  outbreak  ran  for  weeks 
or  months  despite  all  that  was  done,  exhausted  the  mate- 
rial available  to  feed  it,  and  died  out  as  any  fire  will 
if  all  the  fuel  is  burned  up.  Whichever  of  the  "  meth- 
ods "  for  control  happened  to  be  instituted  last  re- 
ceived the  credit  of  conquering  the  outbreak,  although 
none  of  them  had,  as  a  rule,  the  slightest  effect. 

We  know  now,  what  our  forefathers  did  not  know 
then,  that  typhoid  infection  is  carried  by  water,  food, 
flies,  milk,  and  contact,  and  that  "  general  cleaning  up  " 
could  not  remove  infection  from  polluted  water-mains, 
or  purify  a  contaminated  milk  supply;  could  not  stop 
the  eating  of  infected  food  or  eliminate  contact  infec- 
tion.2 The  only  form  of  typhoid  outbreak  which  "  gen- 
eral sanitation  "  could  at  all  affect  was  the  form  due 
to  flies  3  carrying  infected  matter  from  accumulations 

2  Contact  infection  is  the  infection  which  radiates  directly  from 
the  infected  person  through  nose  and  mouth  and  bladder  and 
"bowel  discharges.  The  hands  of  the  infector  and  of  his  asso- 
ciates are  the  chief  carriers  of  all  these  discharges,  although 
mouth-spray  and  sputum  also  act  in  many  diseases.  Things 
directly  infected  by  these  discharges  are  also  dangerous,  but 
practically  only  while  the  discharges  remain  fresh  and  moist. 
The  radius  of  action  of  contact  is  usually  small;  it  compares 
with  the  radius  of  action  of  water,  food,  flies,  and  milk  some- 
what as  a  bayonet  compares  with  a  machine  gun  in  a  general 
melee.  But  contact  infection  in  the  long  run  is  more  deadly 
than  other  routes,  for  there  are  many  "  bayonets  "  to  each  one 
such  "  machine  gun." 

s  We  do  not  now  use  "  general  sanitation "  even  for  fly  out- 


THE  OLD  PRACTICE  AXD  THE  NEW      67 

of  exposed  bowel  discharges,  usually  from  non-fly  proof 
toilets.  In  so  far  as  the  efforts  at  general  sanitation 
may  have  had,  at  times,  some  remote  and  indirect  effect 
on  reducing  the  number  of  flies  or  separating  them  from 
the  infected  discharges,  "  general  sanitation  "  may  have 
at  times  had  some  partial  and  inadequate  but  still  more 
or  less  helpful  results.  But  of  course  the  fly  was  not 
then  known  as  a  route  of  infection  in  typhoid,  so  that 
even  the  results  that  "  general  sanitation  "  secured  were 
secured  largely  by  accident,  i.e.,  by  the  unrecognized 
conjunction  of  an  unappreciated  remedy  with  an  unde- 
termined cause. 

The  present  era  of  "  specific  sanitation  "  began  a  dec- 
ade or  so  ago.  Water,  food,  flies,  and  milk  have  grad- 
ually become  fully  recognized  as  the  main  public  routes 
of  typhoid  infection,  i.e.,  as  the  main  routes  from  indi- 
vidual to  group,  and  from  group  to  group ;  contact,  es- 
pecially of  late,  has  been  recognized  as  the  great  private 
route,  i.e.,  from  individual  to  individual.  Outbreaks 
have  been  met  chiefly  by  finding  the  particular  route 
involved,  and  by  abolishing  or  blocking  that  route. 
But  even  in  this  era,  the  earlier  practice  for  the  attain- 
ment of  this  end  differed  fundamentally  from  that  of 
to-day. 

breaks.  From  this  old  shot-gun  prescription  we  have  eliminated 
all  the  ingredients  but  one,  that  one  which  alone  was  active. 
In  fly  outbreaks  we  exclude  flies  from  infected  discharges,  and 
(so  far  as  the  primary  outbreak  is  concerned)  then  stop.  So 
does  the  outbreak. 


68  THE  NEW  PUBLIC  HEALTH 

The  earlier  epidemiologists  4  of  this  era  argued  thus  : 
"  Water,  food,  flies,  and  milk  are  the  known  public 
routes;  usually  some  one  of  these  routes  is  responsible 
in  each  outbreak.  Therefore,  to  find  the  responsible 
route  in  any  given  instance,  flood  the  stricken  commu- 
nity with  trained  inspectors;  analyze  the  water  sup- 
plies; investigate  the  milk  supplies;  go  through  the 
markets;  delve  into  the  provision  stores;  estimate  the 
number  of  flies,  and  locate  their  breeding-places;  sur- 
vey the  back  alleys  and  out-door  toilets ;  plat  all  results 
on  maps ;  interview  the  city  engineer,  the  fire  marshal, 
the  meat  and  milk  inspectors,  and  examine  their  official 
records;  secure  the  morbidity  and  mortality  records  of 
the  board  of  health;  study  all  available  meteorological, 
topographical,  geological,  and  other  data;  in  brief, 
probe,  dissect,  tabulate,  collate,  and  compare  all  pos- 
sible physical  information  concerning  the  community. 
Under  such  inquisition  the  guilty  route  of  infection 
can  scarcely  escape  detection.' ' 

Eor  these  methods  it  must  be  said  that  they  were 
scientific,  logical,  and  exhaustive;  but  they  were  ter- 
ribly laborious  and  generally  exceedingly  slow.  Of 
course  it  sometimes  happened  that  the  guilty  route  of 
infection  was  stumbled  on  at  once;  and  almost  always 
this  end  was  reached  sooner  or  later,  too  often,  how- 
ever, only  after  weeks,  months,  or  even  years  of  effort. 
The  ponderous  slowness  of  these  methods  took  them 
out  of  the  class  of  effective  emergency  measures,  and 

*  Experts  on  epidemics. 


THE  OLD  PKACTICE  AND  THE  NEW      69 

this  was  recognized  even  then,  for  a  typhoid  investiga- 
tion was  not  then  considered  a  matter  of  haste,  in  initi- 
ation or  in  execution. 

These  earlier  methods  parallel  somewhat  those  which 
we  might  suppose  an  amateur  hunter  to  use,  if  he  were 
commissioned  to  find  a  certain  sheep-killing  wolf. 
Confronted  with  this  problem,  the  amateur  might,  not 
unreasonably,  flood  the  surrounding  mountains  with 
assistants,  instructing  them  to  find  all  the  existing  wolf- 
trails,  and  to  follow  each  such  trail  inward  towards  the 
slaughtered  sheep  until  satisfied  that  it  did,  or  did  not, 
actually  lead  to  them. 

The  methods  of  to-day  are  the  exact  converse  of 
these.  Instead  of  finding  in  the  mountains  and  fol- 
lowing inward  from  them,  say,  500  different  wolf  trails, 
499  of  which  must  necessarily  be  wrong,  the  experi- 
enced hunter  goes  directly  to  the  slaughtered  sheep, 
finding  there  and  following  outward  thence  the  only 
right  trail, —  the  only  trail  that  is  there, —  the  one 
trail  that  is  necessarily  and  inevitably  the  trail  of  the 
one  actually  guilty  wolf. 

THE    NEW    EMERGENCY    EPIDEMIOLOGY 

The  epidemiologist  of  to-day,  called  to  a  typhoid- 
stricken  community,  at  first  pays  no  attention  at  all  to 
the  physical  condition  of  the  existing  possible  routes. 
It  is  sociological  data,  not  physical,  that  he  needs  at 
this  stage.  He  knows  that,  counting  the  wells,  the 
toilets,  the  milk  supplies,  etc.,  there  may  be  500  of 


70  THE  KEW  PUBLIC  HEALTH 

these  possible  routes;  but  be  does  not  go  to  see  them, 
nor  even  the  pumping-station  or  the  sewage-outfall. 
He  goes,  hot  foot,  straight  to  the  "  slaughtered  sheep  " 
—  straight  to  the  patient's  bedside.  There,  and  there 
only,  can  he  expect  to  find  the  trail  of  the  guilty  wolf  — 
the  route  by  which  the  infection  reached  that  patient. 
There,  in  thirty  minutes,  he  reduces  the  500  possibili- 
ties to,  say,  10,  i.e.,  to  those  encountered  (a)  by  this 
patient  5  (b)  at  a  certain  time  (the  date  of  his  infec^ 
tion).  These  10  are  carefully  listed;  but  the  epidemi- 
ologist does  not  investigate  even  these  10.  He  goes, 
instead,  straight  to  another  bedside  and  lists  there  the, 
say,  10  routes  that  constitute  the  possible  routes  for 
this  second  patient;  but  he  does  not  investigate  the 
routes  on  this  list  either;  he  merely  compares  the  two 
lists.  Why?  Because  the  one  guilty  route  quite  evi- 
dently must  be  on  both  lists.  Thus  if  both  lists  show 
the  same  water  supply,  that  water  supply  remains  a 
possible  guilty  route;  but,  if  not,  water  is  eliminated. 
If  both  lists  show  the  same  milk  supply,  that  milk  sup- 
ply remains  a  possible  guilty  route ;  but,  if  not,  milk  is 
eliminated.  Discarding  thus  the  routes  not  common 
to  both  lists,  5  routes,  say,  still  remain.  At  the  third 
patient's  bedside  these  5  are  reduced  by  similar  treat- 
ment, to  say,  3.  So  the  search  goes  on  until  the  epi- 
demiologist either  locates  the  one  main  public  route 

s  Of  course  imported  and  secondary  cases  are  not  used  for  this 
purpose,  and  at  this  stage  the  epidemiologist  is  most  careful  to 
eliminate  all  such  from  his  tabulations. 


THE  OLD  PKACTICE  AND  THE  NEW     71 

common  to  all  or  proves  that  the  outbreak  is  not  due  to 
such  a  public  route  at  all,  but  to  the  private  routes  ex- 
tending directly  from  person  to  person,  i.e.,  to  contact. 
Often  in  twelve  hours  of  such  work,  generally  in  twen- 
ty-four, almost  always  in  thirty-six,  the  evidence  is 
conclusive.  The  guilty  route  stands  out  convicted ;  for 
it  is  found  on  every  list,  and  the  innocent  routes  are 
exonerated,  for  they  occur  only  on  some.6 


Now,  at  last,  and  not  till  now,  does  the  epidemiologist 
deal  directly  with  the  route  of  infection  thus  indicated, 
examine  it  to  find  just  how  it  is  responsible,  including 
the  source  of  its  infection,  and  thus  provide  the  initial 
data  for  its  remedy.7     These  remedies  consist  broadly 

6  Obviously  this  method  fails  if  there  be  but  one  patient,  for 
then  comparison  of  lists  is  of  course  impossible;  but  single 
cases  usually  prove  to  be  imported  or  from  contact.  Also  it  may 
happen  that  even  three  or  four  patients  do  not  furnish  suffi- 
cient data  to  narrow  the  possible  routes  to  one;  obviously,  the 
more  patients  there  are  the  more  conclusive  the  results.  But 
even  when  only  a  few  patients  exist,  this  method  reduces  the 
number  of  routes  to  be  investigated  to  say,  10,  often  to  2  or 
3,  an  immense  reduction  from  the  original  500. 

7  To  those  who  are  not  familiar  with  modern  public  health 
work,  this  account  may  seem  incredible  or  at  least  exaggerated, 
yet  these  are  the  regular  procedures  of  emergency  epidemiology 
wherever  they  are  understood  to-day.  Records  of  such  work 
in  America  for  years  back  are  open  to  all  enquirers.  More- 
over, the  above  account  has  pictured  the  epidemiologist  work- 
ing under  a  most  disadvantageous  condition,  i.e.,  in  complete 
ignorance  of  the  community  he  deals  with,  except  for  what 
he  learns  during  the  investigation  itself.     If  previous  familiarity 


72  THE  NEW  PUBLIC  HEALTH 

in  one  of  two  general  procedures  —  the  prevention  of 
further  infection  of  the  guilty  route  —  or,  if  this  can- 
not he  accomplished,  the  installation  of  some  method  of 
removing  the  infection  after  it  has  been  unavoidably 
admitted.  The  former  method  is  "  the  abolition  of 
the  source/'  the  latter  "  the  blocking  of  the  route." 
As  illustrations  of  the  former  may  be  cited  the  diver- 
sion of  an  infected  feeder  from  an  otherwise  pure 
water  supply;  the  disinfection  of  the  discharges  of 
typhoid  patients  before  deposit  in  outdoor  toilets;  the 
elimination  from  a  milk-business  of  a  typhoid-carrying 
employee;  in  brief,  the  prevention  of  infection  of  the 
public  routes  by  elimination  of  the  sources  of  infection, 
which  are  typhoid-infected  discharges.  As  examples 
of  the  blocking  of  routes  may  be  cited  the  boiling,  the 
chemical  disinfection,  or  the  nitration  of  a  polluted 
water  supply;  the  pasteurization  of  infected  milk;  the 
disinfection  of  the  hands  of  those  who  are  typhoid-car- 
riers or  who  handle  the  typhoid-infected  discharges  of 
others. 

The  simplicity,  effectiveness,  and  inexpensiveness  of 
the  abolition  of  sources  as  compared  with  the  blocking 
of  routes  is  evident  on  a  moment's  consideration.     Yet 

with  the  affected  community  exists,  the  main  public  route  of 
infection  can  often  be  determined  without  leaving  headquarters, 
provided  merely  that  correct  data  as  to  the  number,  location, 
and  dates  of  infection  of  the  cases  are  submitted.  Of  course 
such  "  long-distance  epidemiology,"  wonderfully  accurate  though 
it  can  be  made,  does  not  compare  in  reliability  or  in  finish  of 
detail  with  actual  personal  investigation  on  the  ground. 


THE  OLD  PRACTICE  AND  THE  NEW     73 

in  the  slow  development  of  human  knowledge  and  ap- 
preciation of  their  relative  values,  the  latter  are  still 
relied  upon  as  a  rule  almost  to  the  exclusion  of  the 
former. 

It  is  at  the  point  when  the  guilty  public  route  is 
shown  (if  public  route  there  be)  that  the  epidemi- 
ologist, so  far  as  this  public  route  is  concerned,  steps 
out,  and  the  bacteriologist,  the  chemist,  the  sanitary 
engineer  step  in;  one,  or  any  two,  or  all  three,  as  con- 
ditions may  require.  It  is  they  who  at  the  present 
time  and  as  a  rule  must  work  out  the  most  available 
methods  of  (a)  immediately  ending  present  danger;  (b) 
permanently  providing  against  its  recurrence. 


But  detecting  and  demonstrating  the  guilt  of  a  main 
public  route,  when  such  is  involved,  by  no  means  ends 
the  epidemiologist's  duties.  The  work  outlined  so  far 
is  required  (in  America)  chiefly  in  typhoid  out- 
breaks; and  then  chiefly  in  those  typhoid  outbreaks 
which  are  derived  from  water,  food,  flies,  or  milk. 
The  work  still  to  be  done  is  required  in  all  typhoid 
outbreaks,  whether  initially  derived  from  these  public 
routes  or  from  contact ;  moreover,  it  is  called  for  in  the 
majority  of  outbreaks  of  all  the  other  infectious  dis- 
eases, because  the  majority  are  usually  contact  out- 
breaks at  all  stages.  That  work  is  the  prevention  of 
further  spread  by  contact. 

To  understand  this  clearly,  it  must  be  remembered 


74  THE  NEW  PUBLIC  HEALTH 

that  under  present  conditions  every  typhoid,  or  other, 
epidemic  which  begins  from  some  one  public  route 
(water,  food,  flies,  or  milk)  soon  presents  two  distinct 
parts;  the  primary  outbreak,  consisting  of  that  group 
of  persons  who  received  their  infection  wholesale 
through  the  public  route;  and  the  secondary  outbreak, 
consisting  of  those  individuals  who  later,  by  the  private 
routes  of  contact,  receive  their  infection  individually 
and  directly  from  the  individuals  of  the  primary  set. 
Those  typhoid,  or  other,  epidemics  which  begin  through 
the  private  routes  of  contact,  i.e.,  when  one  infected 
individual  succeeds  in  directly  infecting  a  large  group, 
do  not,  of  course,  present  a  "  primary  "  outbreak  at  all. 
They  are,  so  to  put  it,  "  secondary  "  outbreaks  from  the 
outset.  (Of  course,  it  will  be  understood  that  these  dis- 
tinctions are  somewhat  artificial  and  for  convenience. 
The  so-called  primary  outbreak  affecting  wholesale  a 
group  of  persons  through  a  public  route  of  infection 
such  as  a  public  water  supply,  milk,  etc.,  does  not  truly 
originate  with  the  water,  milk,  etc.,  which  is  involved. 
A  previous  case  or  group  of  cases  must  of  course  have 
infected  the  water  or  milk.  Typhoid  fever  is  not  gen- 
erated by  these  or  any  other  routes;  they  act  merely  as 
transmitters  from  person  or  persons  to  person  or  per- 
sons. The  chain  of  infection  therefore  reaches  back 
into  the  past  indefinitely  to  the  hypothetical  day,  in- 
definite ages  gone,  when  the  typhoid  germ  first  ap- 
peared upon  the  stage  of  the  world's  history.) 

The  search  for  a  public  route  is  therefore  only  the 


THE  OLD  PEACTICE  AKD  THE  NEW     75 

first  step  in  subduing  any  epidemic.  If  such  route 
exist,  this  step,  by  finding  it,  provides  for  getting  rid 
of  it,  which  prevents  the  infection  of  any  more  persons 
from  that  route,  and  so  ends  the  primary  outbreak. 
But  this  first  step  by  no  means  ends  the  epidemic  as  a 
whole,  for  the  persons  already  infected  from  that  pub- 
lic route  constitute  each  one  a  source  of  further  spread 
by  contact,  a  spread  which,  of  course,  must  also  be 
prevented.  Obviously,  epidemics  which  are  contact 
epidemics  throughout,  necessarily  present  an  identical 
problem  from  this  standpoint,  for  every  existing  in- 
fected person,  whatever  the  route  of  his  infection,  is  a 
separate  danger,  and  each  requires  supervision.8 

FINDING    THE    UNKNOWN    CASES 

How  does  the  prevention  of  further  spread  by  contact 
infection  from  existing  cases  depend  on  epidemiology? 
Cannot  the  spread  of  infection  by  contact  from  existing 

s  In  earlier  days  the  fallacy  that  typhoid  fever  patients  could 
not  directly  infect  their  associates  —  in  brief,  that  typhoid  fever 
was  not  contagious  —  was  responsible  for  the  long-delayed  recog- 
nition of  secondary  typhoid  outbreaks,  even  after  the  origin  of 
primary  outbreaks  had  been  learned  and  methods  of  dealing 
with  them  perfected.  We  know  now  that  abolishing  or  blocking 
a  primary  route  is  but  half  the  story.  The  primary  cases,  if 
neglected,  may  continue  to  infect  other  persons  by  contact,  and 
these  again  others,  ad  infinitum.  Such  secondary  outbreaks  may 
extend  slowly  for  months  or  years  and  yield  cases  equaling  or 
exceeding  in  number  those  from  the  primary  outbreak.  The 
"  endemic  typhoid "  of  some  localities  is  at  times  an  unrecog- 
nized, slow-moving,  secondary  outbreak. 


76  THE  NEW  PUBLIC  HEALTH 

cases  be  guarded  against  by  the  attendants  (nurses  and 
physicians)  which  each  such  case  (if  known)  necessarily 
has  ?  True,  and  were  these  known  cases  the  only  dan- 
ger-points, proper  attention  to  preventing  spread  from 
them  would  be  all-sufficient.  But  the  known  cases  usu- 
ally form  but  half  of  the  danger-points  because  only 
half  of  the  dangerously  infected  persons  become  known 
cases.  The  other  half  consists  of  "  missed  cases " 
(mild,  unrecognized,  and  concealed  cases,  early  cases, 
and,  later  on,  convalescing  cases)  and  of  "  carriers." 
(The  "carriers"  are  infected  persons,  capable  of  in- 
fecting others,  but  not  themselves  made  ill  by  the  dis- 
ease germs  which  they  nevertheless  carry  and  distrib- 
ute.) 

Missed  cases  and  carriers,  unless  especially  sought 
for,  are,  and  must  necessarily  remain,  unknown  to  those 
capable  of  guarding  them ;  they  have  no  known  attend- 
ants to  whom  the  prevention  of  spread  of  infection 
from  them  can  be  entrusted;  they  generally  do  not 
know  themselves  to  be  infected;  and,  if  ignored,  they 
are  more  dangerous,  because  inevitably  unguarded,  than 
the  known  cases,  for,  being  known,  the  latter  can  be 
guarded. 

This  problem,  the  finding  of  missed  cases  and  car- 
riers, is  now  solved  by  an  epidemiological  procedure 
which,  while  less  spectacular,  is  far  more  widely  useful 
than  that  of  finding  public  routes,  because  it  applies, 
not  alone  to  contact-typhoid  outbreaks,  but  to  all  con- 
tact outbreaks,  that  is,  to  all  infectious  diseases,  from 


THE  OLD  PEACTICE  AND  THE  NEW     77 

tuberculosis  down.  Were  the  ability  to  find  public 
routes  of  infection  in  water,  food,  fly,  and  milk  out- 
breaks the  only  virtue  of  epidemiology,  its  services,  im- 
mense though  they  have  been  to  the  control  of  primary 
typhoid,  could  have  no  value  in  the  great  mass  of  infec- 
tious disease,  for  the  great  mass  arises  chiefly  by  con- 
tact. It  is  the  ability  to  find  the  private  sources  of  in- 
fection in  contact  outbreaks  that  makes  epidemiology 
the  pivotal  factor  of  modern  public  health. 

This  location  of  missed  cases  and  carriers  in  typhoid, 
and  other,  outbreaks,  is  called  concurrent  epidemiology, 
and  is  well  worth  thoroughly  understanding.  Its  ex- 
planation will  be  found  in  the  next  chapter. 

SUMMAEY 

Modern  public-health  practice  for  the  control  of  in- 
fectious diseases  consists,  not  in  the  physical  surveil- 
lance of  whole  communities,  but  in  the  sociological 
study  of  the  infected  persons  in  them. 

This  practice  is  best  illustrated  in  the  modern  han- 
dling of  typhoid  fever  epidemics,  because  this  disease 
is  all-inclusive,  i.e.,  it  travels  by  all  four  of  the  great 
public  routes  (water,  food,  flies,  and  milk),  as  well  as 
by  the  private  fifth  route,  contact ;  also  because  typhoid 
is  an  intestinal  infection  and,  of  all  the  infectious  dis- 
eases of  the  temperate  zone,  the  intestinal  infections 
alone  travel  by  all  of  these  five  great  routes. 

A  typhoid  epidemic  is  approached,  as  is  any  other 
epidemic,  first,  to  determine  if  any  public  route  of  in- 


78  THE  NEW  PUBLIC  HEALTH 

fection  is  involved,  and,  if  so,  what  that  route  is  and 
how  it  operates,  including  often  how  it  became  infected 
in  the  first  place;  thus  finding  how  to  stop  further 
infection  of  groups  of  people  through  it;  second,  to 
determine  the  private  routes  and  sources  of  the  contact 
outbreak  from  individual  to  individual  which,  sooner 
or  later,  develops  in  all  epidemics,  whether  the  orig- 
inal route  be  a  public  route  or  not. 

To  the  epidemiologist,  the  public-health  detective, 
falls  all  these  crucial  tasks.  It  is  his  function  to  find 
those  underlying  facts  concerning  the  sources  and 
routes  of  infection  which  alone  can  form  a  sound  basis 
for  real  remedial  measures. 

How  he  performs  the  finding  of  public  routes  and 
often,  of  the  sources  of  their  infection,  has  been  de- 
scribed; the  finding  of  private  routes  and  sources  will 
be  described  later.  In  both  procedures  the  initial  step 
is  the  same,  namely,  the  investigation  of  the  known 
cases.  By  seeing  and  questioning  known  cases,  or  their 
immediate  relatives  and  attendants,  the  epidemiologist 
can  classify  them  into  native  and  imported.  The  na- 
tive cases,  since  they  alone  originated  in  the  community 
under  investigation,  are  further  classified  into  primary 
and  secondary  cases.  From  the  histories  of  the  pri- 
mary cases,  if  such  there  be,  he  learns  the  public  route 
and  provides  thus  the  data  for  its  abrogation.  From 
all  the  cases,  imported,  primary,  and  secondary,  he  ob- 
tains the  data  needed  for  the  next  step. 


CHAPTER  VIII 
THE  NEWEST  PRACTICE 


The  preceding  chapter  outlined  the  first  step  in  the  modern 
handling  of  a  typhoid  fever  epidemic,  typhoid  fever  being 
selected  because  its  proper  handling  illustrates  best  the  prin- 
ciples and  practice  of  modern  public  health  work. 

The  first  step  is  the  discovery,  by  the  methods  of  emergency 
epidemiology,   whether  water,   food,   flies,   milk,   or   contact 

i  Emergency  epidemiology  is  the  epidemiology  required  in  out- 
breaks from  single  great  routes  —  water,  food,  flies,  milk.  Con- 
current epidemiology  is  the  epidemiology  required  in  contact 
outbreaks,  i.e.,  outbreaks  from  multiple  private  sources.  Emer- 
gency epidemiology  is  rapid  and  spectacular;  it  is  played  hard, 
against  time,  to  save  large  groups  of  people.  Concurrent  epi- 
demiology is  relatively  slow  and  plodding;  it  ferrets  out,  one  by 
one,  the  individual  persons  whose  infection  threatens  families 
or  small  groups.  Emergency  epidemiology  will  disappear  when 
the  great  routes  are  properly  protected  by  purification  methods 
or,  even  better,  by  such  supervision  of  all  cases  that  infection 
of  such  routes  becomes  impossible.  Concurrent  epidemiology 
will  greatly  develop;  it  is  the  most  powerful  and  practical 
weapon  yet  devised  for  the  abolition  of  the  infectious  diseases 
and  hence  for  doing  away  with  the  necessity  of  guarding  routes 
at  all.  To  revert  to  the  wolf  parable,  guarding  the  routes  by 
which  the  wolves  may  reach  the  sheep  is  good,  provided  eternal 
vigilance  and  a  uniformly  high  standard  of  efficiency  are  main- 
tained. Abolition  of  the  wolves  themselves  is  far  more  con- 
clusive, and  would  make  unnecessary  the  burden  of  guarding  the 
routes  for  all  time. 

79 


80  THE  NEW  PUBLIC  HEALTH 

be  the  original  main  route  of  infection.  The  second  step, 
to  be  outlined  in  these  pages,  is  the  location,  by  the  methods 
of  concurrent  epidemiology,  of  all  the  infected  persons 
(known  cases,  missed  cases,  and  carriers).  These  are  located 
because  each,  regardless  of  the  original  route  by  which  he 
himself  became  infected,  forms  a  new  center  of  infection  for 
spread  by  contact  which  will  continue  the  outbreak  in- 
definitely until  such  transfer  is  stopped,  accidentally,  or  by 
exhaustion  of  susceptible  material. 

It  was  further  pointed  out  that  neither  emergency  epi- 
demiology nor  concurrent  epidemiology  were  limited  in 
their  application  to  typhoid  fever;  and  that  the  ability  of 
concurrent  epidemiology  to  handle  properly  contact  typhoid 
outbreaks,  whether  contact  be  the  secondary  or  primary 
route,  is  a  conclusive  demonstration  of  its  ability  to  handle 
all  other  infectious  diseases,  since  these  others,  while  spread 
by  public  routes  to  some  extent,  are,  in  the  mass,  contact 
infections  chiefly.  No  dependence  on  the  argument  by 
analogy  from  typhoid  fever  to  other  diseases  is  needed,  how- 
ever; for  these  other  diseases  are  now  and  have  been  for 
years  past  handled  successfully  by  these  very  methods. 

Most  persons  contemplating  the  problem  of  finding 
missed  cases  and  carriers  for  the  first  time,  pronounce 
it  impossible;  then  suggest,  as  the  only  solution,  a 
house-to-house  canvass  of  the  whole  community,  hastily 
adding  that  of  course  such  a  measure  is  quite  imprac- 
tical. As  a  matter  of  fact,  the  public  health  detective 
does  at  times  use,  and  use  successfully,  exactly  that 
"  impractical  "  measure, —  the  house-to-house  canvass. 
This  house-to-house  method  is  used  in  primary  out- 
breaks from  public  routes,  to  locate  unreported  primary 
a  known  cases,"  and  also  to  locate  primary  missed  cases 


THE  NEWEST  PRACTICE  81 

and  carriers.  It  is  necessary  in  such  primary  out- 
breaks because  the  distribution  of  primary  missed  cases 
and  carriers,  as  well  as  of  "  known  cases/'  is  co-exten- 
sive with  that  of  the  guilty  route.  There  is  no  other 
guide  to  their  location,  and  therefore  the  whole  distri- 
bution of  the  guilty  route  must  be  searched.  But  the 
need  of  such  a  canvass  of  a  whole  community  seldom 
arises  except  in  typhoid  or  other  infectious  intestinal 
outbreaks;  and  then  only  when  the  infection  is  spread 
by  a  route  common  to  the  whole  community ;  and  there- 
fore practically  only  when  the  guilty  route  is  a  public 
water  supply.  In  milk  outbreaks,  those  who  did  not 
use  the  guilty  milk  need  not  be  examined ;  and  a  similar 
statement  is  true  also  regarding  food  outbreaks.  Ely 
outbreaks  rarely  affect  a  whole  community  unless  the 
community  be  very  small ;  and  in  small  communities  of 
course  a  general  canvass  is  not  difficult. 

In  the  majority  of  epidemics,  and  because  the  major- 
ity of  epidemics  are  due,  not  to  great  public  routes,  but 
to  private  contact,  the  finding  of  missed  cases  and  car- 
riers does  not  require  even  a  partial  house-to-house  can- 
vass. This  is  true  of  secondary  typhoid,  and  other 
secondary  outbreaks  (which  are  contact  outbreaks)  as 
well  as  of  the  great  majority  of  all  outbreaks  (since  the 
majority  are  contact  outbreaks  only). 

The  reason  why  missed  cases  and  carriers  can  be 
found  in  contact  outbreaks  without  a  house-to-house 
canvass  depends  upon  a  fact  of  which  the  true  signifi- 
cance is  not  fully  appreciated  outside  of  epidemiologi- 


82  THE  NEW  PUBLIC  HEALTH 

cal  circles.  It  is  this:  such  missed  cases  and  carriers 
are  not  distributed  at  pure,  blind  random  anywhere  and 
everywhere  throughout  the  community.  They  occur  in 
certain  groups  —  and  these  groups  can  be  located  be- 
cause they  betray  themselves  through  their  connection 
with  known  cases.  Hence  the  location  of  known  cases 
locates  these  groups  also.2 

This  most  important  epidemiological  principle  is 
called  the  principle  of  zones  of  infection.  It  is  the  car- 
dinal principle  of  concurrent  epidemiology. 

The  principle  of  zones  of  infection  was  first  clearly 
recognized  in  diphtheria  epidemics,  and  its  develop- 
ment and  demonstration  as  a  practical  working  rule  de- 
pends, primarily,  on  diphtheria  investigations ;  3  but 
both  principle  and  practice  have  now  been  established 
for  all  the  well-studied  epidemic  diseases. 

The  epidemiologist,4  in  putting  this  principle  into 
practice,  locates  first  the  known  cases,  and  then  searches 

2  It  must  not  be  supposed  that  these  groups  are  confined  to 
families,  immediate  neighbors,  etc.  Their  true  basis  is  socio- 
logical relationship,  not  mere  physical  propinquity.  In  a  single 
scarlet  fever  outbreak  originating  in  one  community  Dr.  A.  J. 
Chesley  found  the  related  sociological  groups  distributed  in  3 
States,  involving  3  cities,  2  villages,  and  24  townships  in  10 
counties.  The  Mankato  typhoid  fever  outbreak  of  1908  affected 
over  40  points  outside  of  Mankato. 

3  Developed  largely  by  Drs.  F.  F.  Wesbrook,  L.  B.  Wilson,  and 
O.  McDaniel  in  Minnesota. 

*  It  must  be  evident  that  those  private  practising  physicians 
who  are  not  health  officers,  cannot,  for  many  reasons  well  under- 
stood by  the  profession,  do  epidemiological  work,  emergency  or 
concurrent,   except   in   overwhelming  outbreaks,   where   ordinary 


THE  NEWEST  PKACTICE  83 

the  zones  of  infection,  which  they  indicate,  for  missed 
cases  and  carriers.  The  methods  of  this  search  vary 
with  each  disease  and  are  described  in  some  detail  in 
other  chapters.  Detective  methods  are  used,  illumi- 
nated by  expert  technical  knowledge  of  each  disease, 
its  natural  history,  and  the  means,  laboratory  and 
clinical,  of  recognizing  it,  at  every  stage  and  under  all 
disguises.  Suffice  it  to  say  now  that  the  finding  of 
missed  cases  and  carriers,  as  well  as  of  known  cases, — 
that  is,  of  the  very  framework  of  the  ramifying  threads 
of  the  infectious  disease, —  is  a  problem  not  only  solv- 
able, but  already  solved,  and  already  reduced  to  a 
routine  basis.  As  an  art,  this  concurrent  epidemiology 
is  somewhat  more  arduous  and  time-consuming  than 
the  art  of  emergency  epidemiology,  but  it  is  thoroughly 

conventions  and  social  relations  are  temporarily  foregone.  Even 
those  private  practicing  physicians  who  are  also  health  officers, 
encounter  difficulties  and  obstructions,  ethical,  social  and  con- 
ventional, which  professional  epidemiologists,  who  are  not  in 
private  practice,  do  not  meet.  Hence  in  all  outbreaks  the  physi- 
cian finds  that  his  most  valuable  functions  consist  in  treating 
the  sick  and  in  advising  protective  measures  to  those  who  apply 
to  him.  Physicians  also  often  combine,  very  successfully,  to 
publish  material  or  give  public  lectures  of  instructions  during 
epidemics.  But,  after  all,  the  chief  service  which  the  physician 
can  render  to  official  public  health  is  the  reporting  of  known 
cases.  Known  cases,  as  has  been  shown,  are  the  basic  datum- 
points  for  emergency  epidemiology,  i.e.,  for  the  finding  of  the 
routes  of  infection;  and  they  are  even  still  more  important  to 
concurrent  epidemiology,  i.e.,  in  the  study  of  the  zones  of  infec- 
tion. Epidemiology  is  greatly  aided  when  the  physician  per- 
forms thoroughly  this,  his  primary,  public  health  duty. 


84  THE  NEW  PUBLIC  HEALTH 

practical  and  has  been  successfully  followed  for  years 
past  all  over  Minnesota,  in  an  average  of  four  to  six 
epidemics  every  week.5  The  visiting  nurse  in  "  con- 
current epidemiology,"  can  be  made  a  most  valuable 
and  efficient  aid,  to  say  nothing  at  present  of  the  other 
and  even  more  indispensable  services  in  other  direc- 
tions which  are  within  her  especial  province. 

This  principle  of  zones  of  infection  applies  to  tuber- 
culosis just  as  to  any  other  infection  spread  by  contact ; 
indeed,  the  location  of  missed  cases  in  tuberculosis 
(carriers  in  tuberculosis  are  hypothetical  to  date)  offers 
less  difficulty  to  modern  epidemiology  than  the  same 
problem  in  other  infectious  diseases. 

FTJTUKE   APPLICATIONS 

So  much  for  past  and  present  practice. 

Turning  now  to  the  future  era  of  "  supervision  of 
sources,"  the  principles  and  practice  already  described 
pave  the  way  for  appreciation  of  the  probable  develop- 
ments. In  reconsidering  the  wolf  metaphor  already 
outlined,  every  one  will  ask,  and  wisely,  Why  wait  until 
some  sheep  are  killed  before  we  protect  the  others? 
Why  not  patrol  the  known  routes  by  which  the  wolves 
reach  the  sheep;  or,  better,  build  wolf -proof  folds;  or, 
best  of  all,  teach  the  sheep  to  protect  themselves  —  to 
fight  the  wolves  or  at  least  to  dodge  them  ? 

Those  who   believe   that   infectious   disease  can   be 

s  See  reports  of  the  Minnesota  State  Board  of  Health  for  1911 
and  1913. 


THE  NEWEST  PEACTICE  85 

warded  off,  in  the  face  of  infection,  by  diet,6  exercise, 
good  ventilation,  and  "  strict  observance  of  the  laws  of 
bodily  health/'  are  those  who  would  train  the  sheep  to 
fight ;  would  train  the  body  to  destroy  all  infection  that 

6  A  most  important  exception  to  the  general  statement  that 
proper  diet  in  itself  cannot  prevent  the  development  of  infection 
provided  infection  gains  access  to  the  body  should  be  recorded  to 
cover  the  case  of  nursing  infants.  It  has  long  been  noted  that 
breast-fed  infants,  during  the  period  that  they  are  so  fed  (but 
during  that  period  only)  are,  practically  speaking,  immune  to 
many  infectious  diseases.  This  is  so  true  of  scarlet  fever  and 
measles,  that  in  such  diseases  no  great  concern  need  be  felt 
for  such  an  infant,  even  though  the  mother  herself  have  the 
disease.  In  diphtheria,  a  nursling  to  some  extent  shows  a  like 
immunity.  In  smallpox,  this  is  not  true  and  in  tuberculosis  it 
is  at  most  very  doubtful. 

That  this  escape  of  nurslings  is  purely  a  matter  of  the  enor- 
mous advantages  in  nutritional  value,  to  an  infant,  of  mother's 
milk  over  other  foods  has  yet  to  be  demonstrated.  Nursing 
infants  are  by  the  mere  fact  of  nursing  less  likely  than  are  other 
infants  to  be  exposed  to  whatever  routes  or  sources  of  infection 
may  be  about,  unless  the  mother  is  herself  a  source.  But  in 
scarlet  fever  and  measles,  at  least,  this  is  not  the  whole  ex- 
planation. It  has  been  suggested  that  the  real  reason  lies  in 
the  transmission  to  the  child  of  actual  immunity-producing  bodies 
in  mother's  milk.  If  this  be  so,  breast-feeding  in  infants  as  a 
protection  against  certain  infectious  diseases  combines  in  one 
operation  three  principles  of  defense;  good  nutrition,  specific 
immunization  and  the  avoidance  of  infection.  Other  forms  of 
feeding  fail  to  provide  these  defences;  and  usually  combine 
against  the  infant  poor  nutrition,  absence  of  immunization,  and 
exposure  to  the  five  routes  of  infection.  Great  skill  and  care 
and  constant  watchfulness  may  serve  in  artificial  feeding  par- 
tially to  offset  these  dangers;  breast-feeding  automatically  pro- 
tects against  them  almost  without  effort.  Moreover,  breast-feed- 
ing accomplishes  in  other  icays  four  times  the  service  in  saving 


86  THE  KEW  PUBLIC  HEALTH 

may  reach  it.  But,  as  we  do  not  know  how  to  teach 
sheep  to  fight,  so  we  do  not  know  the  laws  of  health 
needed  for  this  purpose  if  any  such  exist.7  Such  meth- 
ods tested  against  infection  have  generally  failed8  so 
far.  In  that  day  when  sheep  fight  wolves  they  may 
succeed. 

Those  who  believe  that  the  sheep  may  be  taught  to 
dodge  the  wolves  have  much  more  in  their  favor. 

Dodging  infection  is  well  understood.  The  phy- 
sician, the  nurse,  the  epidemiologist,  handle  with  im- 
punity the  very  sources  of  infection  themselves, —  in- 
fected persons  and  their  infected  discharges.  Why  not 
teach  this  art  to  every  citizen  ?  The  principle  is  sim- 
ple,—  prevent  infected  discharges  from  entering  the 
mouth.  It  is  in  the  practising  of  this  principle,  simple 
as  it  is,  that  the  inexperienced  person  fails.  A  single 
slip  may  be  fatal,  and  slips  are  constantly  made.  More- 
infants'  lives  that  it  accomplishes  in  cutting  out  infectious  dis- 
eases. (The  writer  wishes  to  record  his  indebtedness  to  Dr. 
J.  P.  Sedgwick,  of  Minneapolis,  for  much  valuable  information 
on  this  subject.) 

i  Once  more  we  beg  our  readers  not  to  think  that,  because 
building  up  the  body  cannot  make  it  proof  against  infectious 
diseases,  building  up  the  body  should  be  abandoned.  To  say 
that  physical  care  of  the  body  never  made  a  Newton  or  a  Shake- 
speare is  not  to  say  that  no  man  need  care  for  his  physical 
welfare.  The  laws  of  physical  health,  even  so  little  as  we  know 
of  them,  have  many  virtues.  Because  protection  from  infectious 
diseases  is  not  one  of  them  detracts  no  whit  from  any  of  the 
others. 

s  Tuberculosis  and  pneumonia  are  often  held  exceptions  to  this 
rule,  but  that  they  are  exceptions  is  being  questioned. 


THE  NEWEST  PEACTICE  87 

over,  to  guard  against  those  infected  persons  who  are 
not  recognized  as  such,  means  that  all  discharges  must 
be  kept  out  of  all  mouths  at  all  times, —  a  theoretically 
possible,  but,  to  the  vast  majority  of  the  work-a-day 
world,  a  practically  wholly  impossible,  performance. 
If  we  give  up  in  despair  the  hope  of  excluding  all  dis- 
charges from  all  mouths  and  attempt  to  teach  the  ordi- 
nary citizen  to  recognize  infection  so  that  he  may  avoid 
at  least  infected  discharges,  we  shall  be  attempting  to 
make  of  each  citizen,  man,  woman,  and  child,  a  highly 
trained  physician.  To  teach  personal  defense  against 
infection  is  a  great  thing  for  those  who  have  the  oppor- 
tunity to  learn  and  the  incentive  to  practice  it.  As  a 
general  method  for  abolishing  infectious  diseases  it  is 
quite  hopeless ;  nevertheless,  each  citizen  should  have  the 
chance  to  know  at  least  the  principles  and  these  should 
be  taught  in  every  school  in  the  land. 

Those  who  believe  that  infectious  disease  should  be 
warded  off  by  specific  immunization  have  some  sure 
ground  to  go  upon ;  but  the  scope  of  immunization  is  at 
present  small.  These  are  they  who  would  build  wolf- 
proof  folds;  but  we  do  not  know  how  to  build  folds 
which  will  be  proof  against  all  kinds  of  these  wolves. 
It  is  true  we  know  how  to  build  a  fold  which  is  proof 
against  smallpox,  and  that  is  vaccination.  Also  we  have 
lately  completed  a  fold  proof  against  typhoid,  which  is 
antityphoid  inoculation.  But,  alas,  granting  such  folds 
are  built,  driving  the  sheep  into  them  is  a  procedure 
forbidden  to  public  health,  except  under  martial  law. 


88  THE  NEW  PUBLIC  HEALTH 

In  vaccination  and  in  antityphoid  inoculation  the  old 
adage  still  applies:     "  Eirst  catch  your  sheep." 

Those  who  believe  in  guarding  routes  of  infection  are 
those  who  would  patrol  the  approaches  to  the  sheep. 
This  is  at  least  a  possible  method,  already  established  as 
of  great  value  in  some  diseases.  But  a  consideration  of 
the  following  table  shows  that,  like  immunization,  its 
scope  is  limited.  Its  scope  is  broader  than  that  of  im- 
munization, but  it  is  not  broad  enough  to  cover  all  in- 
fectious diseases. 

If  we  tabulate  the  different  infectious  diseases  occur- 
ring in  the  temperate  zone  on  the  .basis  of  their  chief 
routes  of  transmission  we  find  that  water,  food,  flies, 
and  milk  are  the  main  public  routes ;  the  many  private 
routes  we  group  under  contact;  but  not  every  route 
operates  in  every  disease.     Thus: 

The  Chief  Infectious  Diseases  of  the  Temperate  Zone  classi- 
fied by  their  Chief  Routes  of  Infection 

Typhoid  fever  (and  other 

intestinal       infections) 

are  carried  chiefly  by  . . .  .water;  food;  flies;  milk;  contact. 
Tuberculosis  (human)  9  is 

carried  chiefly  by flies ; 10  milk;  contact. 

9  Bovine  tuberculosis  is  of  course  derived  chiefly  from  the 
milk  of  tuberculous  cows.  In  many  ways  this  disease  is  best 
separated  for  administrative  purposes  from  human  tuberculosis. 
The  carriage  of  human  tuberculosis  in  milk  referred  to  in  the 
table  is  that  dependent  on  the  infection  of  milk  by  tuberculous 
milk  handlers. 

10  Insignificant. 


THE  NEWEST  PKACTICE  89 

Diphtheria,  scarlet  fe- 
ver, measles,  German 
measles,  mumps, 
whooping-cough,  small- 
pox, chickenpox  are 
carried  chiefly  by milk ;  contact. 

Syphilis,  gonorrhea, 
trachoma,  cerebro-spinal 
meningitis,  leprosy  are 
carried  chiefly  by contact 

Hence  water  and  food,  as  great  public  routes  of  com- 
munity infections,  carry  only  the  intestinal  infectious 
diseases.  Elies,  practically  speaking,  also  carry  this 
group  only,  the  amount  of  tuberculosis  carried  by  flies 
being  small.  Milk  carries  many  infectious  diseases,  but 
contact  alone  carries  all. 

If  we  guard  only  water  supplies  against  infection,  we 
eliminate  water-borne  intestinal  infections  (this,  so  far 
as  typhoid  is  concerned,  would  be  perhaps  one-third  of 
the  total  typhoid  in  America).  We  leave  untouched 
intestinal  infections  carried  by  food,  flies,  milk,  and 
contact.  Also  we  leave  untouched  all  other  infectious 
diseases.11  If  we  guard  food,  as  well  as  water,  we 
eliminate  such  intestinal  infections  as  are  carried  by 
food  and  water,  but  the  fly,  milk,  and  contact  routes  for 
these  remain;  so  do  all  routes  which  carry  xhe  other 
infectious  diseases. 

11  Hazen's  theorem  —  that  infected  water  supplies  carry  all  the 
infectious  diseases  —  is  an  unproved  and  much  disputed  hypoth- 
esis as  yet. 


90  THE  NEW  PUBLIC  HEALTH 

If  we  eliminate  flies  also,  fly  typhoid  and  its  con- 
geners go,  but  milk  and  contact  typhoid  still  remain 
with  us.  It  is  true  that  a  slight  effect  on  tuberculosis 
also  might  be  noted,  but  nothing  else  is  touched.  If  we 
guard  milk  supplies  against  infection,12  we  begin  to 
make  great  strides,  but  contact,  the  great  route  of  human 
tuberculosis  and  of  all  the  other  infectious  diseases,  in- 
cluding the  intestinal,  still  will  operate. 

The  fact  is  that  while  public  water,  food,  fly,  and 
milk  infections  parallel  invasion  by  wolves  coming  from 
without,  contact  infection  parallels  the  presence  amongst 
the  sheep  themselves,  of  "  wolves  in  sheep's  clothing." 
Such  wolves,  because  intermingled  with  the  sheep,  can- 
not possibly  be  eliminated  by  guarding  the  approaches. 

If,  then,  the  guarding  of  public  routes  can  exclude 
only  some  of  the  infection,  what  remains  ? 

The  extermination  of  all  the  wolves  —  the  abolition 
of  the  sources  of  infection. 

If  our  modern  wolf -hunters  can  find  the  undisguised 
wolves  and  even  the  wolves  in  sheep's  clothing,  after 
the  sheep  are  slain,  why  cannot  they  find  them  also 
before  the  sheep  are  slain?  If  the  very  sources  of  in- 
fection (known  cases,  missed  cases,  and  carriers)  can- 

12  A  great  deal  of  the  alleged  milk  supervision  of  to-day  to 
prevent  watering  or  to  keep  up  the  fat  standard  has  no  relation 
whatever  to  guarding  milk  against  infection.  Even  the  campaign 
for  clean  milk  eliminates  dirt  chiefly.  Unless  especially  con- 
ducted to  prevent  infection,  it  fails  on  this  latter  score  com- 
pletely. Most  public  health  authorities  now  recommend  heating 
even  the  "  cleanest "  milk  as  the  only  real  safeguard. 


THE  NEWEST  PKACTICE  91 

not  escape  our  epidemiologists  armed  with  their  mod- 
ern principles,  why  wait  for  an  epidemic  before  we  go 
after  them  at  all  ? 

Turn  again  to  the  table  and  see  that  if  we  begin  oper- 
ations for  control  with  water,  we  must  move  through 
food  and  flies  and  milk  to  contact  before  we  have  in- 
cluded all  even  of  typhoid ;  and  until  we  reach  contact, 
we  do  not  begin  to  touch  the  bulk  of  the  other  diseases 
at  all.  But  if  we  begin  with  control  of  contact,  we 
find  that  the  method  which  eliminates  contact  infection 
necessarily  eliminates  the  other  forms  also.  That 
method  when  shorn  of  non-essentials  is  the  supervision 
of  all  infectious  persons. 

THE   NEW   PROGRAM 

To  drop  metaphors,  the  new  program  of  official  pub- 
lic health  is  the  abolition  of  the  infectious  diseases. 

The  measures  proposed  for  this  purpose  in  progres- 
sive order  of  general  efficiency,  from  lowest  to  highest, 
are  — 

1.  The  securing  to  each  individual  citizen  continu- 
ously of  his  highest  possible  general  physical  health. 
Ideal  as  this  is  as  an  end  in  itself,  it  can  have  little 
effect  on  most  infectious  diseases,  except  indirectly  dur- 
ing infancy,  although  it  is  acclaimed  as  a  factor  in  re- 
ducing tuberculosis  and  pneumonia  even  in  adults. 

2.  The  securing  to  each  individual  citizen  of  instruc- 
tion and  training  in  the  personal  conduct  which  he  must 
follow  in  order  to  avoid  receiving  into  his  body  the  dis- 


92  THE  NEW  PUBLIC  HEALTH 

charges  of  infected  persons.  This  as  a  system  is  per- 
fect, but  the  securing  of  the  daily  carrying  out  by  every 
one  of  the  personal  conduct  needed  is  a  hopeless  dream. 

3.  The  securing  to  each  individual  of  continuous  spe- 
cific immunization.  Technically  practical  as  yet  only 
against  smallpox  and  typhoid  fever  by  inoculation,  and 
in  infancy  against  certain  infections  by  breast-feeding, 
the  scope  of  this  procedure  is  very  limited ;  and  it  must 
be  remembered  that  the  public  have  never  yet  adopted 
even  smallpox  immunization,  except  under  compulsion, 
to%an  extent  sufficient  to  abolish  even  this  one  disease. 

These  three  measures  place  the  abolition  of  infection 
directly  upon  the  individual,  as  though,  to  abolish  foot- 
pads, we  should  arm  each  citizen  and  train  him  in 
jiu  jitsu;  or  as  though,  because  of  one  free  wolf,  we 
should  put  five  hundred  sheep  in  armor.  The  three 
measures  which  follow  place  the  abolition  of  infection 
directly  upon  a  very  small  group  of  experts  who  deal 
directly  with  the  infection  itself.  These  three  measures 
would  put  the  one  wolf  in  bonds,  and  let  the  five  hun- 
dred sheep  go  free. 

4.  The  physical  supervision  of  the  four  great  public 
routes  of  infection  (public  water  supplies,  public  food 
supplies,  flies,  which  are  public  property,  and  public 
milk  supplies)  to  exclude  all  discharges  from  them. 
The  principles  are  well  understood,  but,  in  practice, 
systematic  application  usually  is  lacking.  (Physical 
supervision  of  such  public  and  private  surroundings  as, 
by  their  effect  on  conduct,  may  bear  on  the  operation 


THE  NEWEST  PRACTICE  93 

of  the  fifth  and  greatest  route  of  all,  i.e.,  contact,  now 
more  or  less  efficiently  attempted  in  housing  and  settle- 
ment movements,  is  necessarily  at  present  more  a  matter 
of  education  than  of  official  action,  especially  where  pri- 
vate surroundings  are  involved.) 

5.  The  physical  supervision  of  all  known  infectious 
cases  to  exclude  their  infected  discharges  from  all  routes. 
This,  thoroughly  done,  would  make  a  tremendous  im- 
pression on  infectious  disease.  But  known  cases  form 
not  more  than  half  the  total  sources  of  infection. 

6.  The  sociological  supervision  of  all  infectious  'per- 
sons. These  are  the  sources  of  infectious  diseases. 
Once  found  and  supervised,  infection  from  the  human 
must  stop  in  toto. 

For  the  first  three  measures,  education,  demonstra- 
tion, persuasion,  are  the  things  required;  but  also  the 
abolition  of  carelessness,  poverty,  and  the  pressure  of 
necessity.  Knowledge  alone  is  not  enough;  time  and 
facilities  to  do  with  are  needed  also.  To  supply  all 
these  to  every  citizen,  man,  woman  and  child,  is  an  ideal 
to  be  sought  by  every  path ;  but  an  ideal  that  will  take 
long  years  to  realize. 

For  the  second  three  we  have  principles  and  practice, 
precedent,  authority,  some  law,  and  the  hearty  support 
of  public  opinion  in  epidemics.  We  need  a  few  new 
laws.  Chiefly  wTe  need  proper  organization  and  in- 
creased equipment;  but,  more  than  all,  the  hearty  sup- 
port of  public  opinion,  continuously,  not  in  epidemics 
only. 


94  THE  KEW  PUBLIC  HEALTH 

Of  all  these  measures,  the  last  is  certainly  the  most 
inclusive;  properly  done,  it  excludes  the  need  (so  far  as 
abolition  of  infectious  diseases  is  concerned)  of  all  the 
others.  It  is  cheaper,  simpler,  easier,  more  direct  and 
rapid  than  any  other,  and  does  not  "  interfere "  with 
every  citizen,  in  every  act  of  daily  life,  indefinitely,  for 
it  deals  with  but  one  small  class  (infected  persons),  and 
only  while  infective;  and  it  deals,  even  with  them, 
merely  to  the  extent  of  preventing  the  spread  to  others 
of  their  infected  discharges. 


CHAPTER  IX 
INDIVIDUAL  DEFENSE 

PUBLIC    DEFENSE    AND    PRIVATE 

The  preceding  chapter  distinguished  sharply  those 
things  necessary  to  escape  existing  chances  of  infection, 
which  individuals  may  do,  from  those  things  necessary 
to  prevent  chances  of  infection  from  existing  at  all, 
which  latter  communities  must  do,  if  it  be  done  at  all, 
because  individuals  cannot. 

The  present  chapter  will  outline  the  former,  the  in- 
dividual's part  in  protecting  himself.  As  already  indi- 
cated, these  individual  efforts  may  be  made  in  three 
directions : 

1.  To  secure  high  general  physical  health. 

2.  To  secure  specific  immunity  to  specific  diseases. 

3.  To  avoid  disease,  especially  infectious  disease. 

Efforts  made  in  the  first  direction  aim  to  build  up 
and  make  palaces  of  the  bodies  in  which  we  dwell  and 
which,  too  often,  are  mere  hovels;  but,  alas,  the  non- 
fireproof  palace  burns  as  easily  as  the  non-fireproof 
hovel.  It  is  futile  to  seek  the  physical  advancement  of 
the  race  in  order  to  abolish  disease.     -We  should  seek 

95 


96  THE  XEW  PUBLIC  HEALTH 

the  abolition  of  disease  in  order  to  physically  advance 
the  race.1 


DISEASES 

True,  we  should  not  await  the  abolition  of  disease  be- 
fore seeking  general  physical  advancement,  but,  unfor- 
tunately for  the  achievement  of  very  much  real  progress 

a  No  greater  fallacy  burdens  public  health  advance  than  the 
idea  that  high  health  protects  against  infection.  Every  health 
officer  scouts  this  idea  when  it  is  presented  to  him  by  an  anti- 
vaccinationist  to  show  that  vaccination  is  unnecessary  —  scouts 
it  when  it  is  offered  as  an  excuse  for  neglecting  quarantine  — 
scouts  it  when  father,  mother,  nurse,  wife,  husband  urge  it  as 
a  reason  why  he  or  she,  untrained  in  self-protection,  should  brave 
infection  at  the  side  of  a  loved  one.  Yet  almost  every  health 
officer  will  urge  it  in  his  next  bulletin  or  in  his  next  address! 
The  statement  that  high  health  is  an  efficient  protection  against 
infection  is  either  true  or  not  true.  When  athletes,  soldiers  in 
the  pink  of  condition,  lumbermen,  fail  to  succumb  to  syphilis, 
gonorrhea,  typhoid,  pneumonia,  it  will  be  time  to  consider  high 
health  as  a  possible  reason  for  their  escape.  Until  that  time  this 
wretched  quibble  should  be  abandoned  by  all  who  hope  to  teach 
the  truth  according  to  the  evidence. 

The  Agricultural  colleges  and  experiment  stations,  dealing 
with  the  physical  development  of  stock  animals  to  the  highest 
point,  have  found  that  such  high  physical  development  does  not 
prevent  or  minimize  infection.  It  is  high  grade  stock,  rather 
than  scrub,  which  suffers  infections.  Immunity  to  certain 
diseases  has  been  secured  by  careful  breeding  amongst  plants 
(rustless  wheat  for  instance),  but  not  amongst  animals  to  any 
practical  extent.  (Permission  to  quote  their  names  in  support 
of  this  footnote  has  been  granted  by  Dean  A.  F.  Woods  of  the 
University  of  Minnesota  Agricultural  Department,  and  by  Prin- 
cipal F.  C.  Harrison  of  the  MacDonald  College,  Quebec.) 


INDIVIDUAL  DEFEXSE  97 

in  this  line,  we  know  as  yet  few  practicable  rules  of 
general  application,  except  for  infants,  to  achieve  such 
physical  advancement.  Far  better  than  how  to  secure 
high  physical  health  we  know  how  to  avoid  disease,  at 
least,  how  to  avoid  certain  diseases.  A  few  of  these  are 
non-infectious  environmental  diseases,  like  scurvy  and 
miner's  elbow;  and  the  non-infectious  poisonings,  like 
those  from  lead,  arsenic,  phosphorus,  alcohol,  and  illu- 
minating gas.  These  diseases  depend  upon  readily  rec- 
ognized mechanical  or  physical  surroundings.  A  change 
of  diet  in  scurvy  or  of  position  in  miner's  elbow;  stop- 
ping leaks  in  pipes  for  illuminating  gas  poisoning; 
refusal  to  admit  the  other  poisons  to  the  body  —  and 
all  are  abolished.  But  after  all,  these  non-infectious 
poisons  furnish  but  1  in  1,000  of  all  deaths,  except  in 
infancy,  where  non-infectious  intestinal  poisonings 
probably  furnish  a  large  proportion. 

On  the  other  hand,  the  poisonings  which  are  infec- 
tious, i.e.,  the  infectious  diseases,  furnish  more  than 
one-sixth  of  all  the  deaths,  and  about  one-half  of  these 
deaths  are  from  but  one  infectious  disease,  namely,  con- 
sumption. Like  the  chemical  poisonings, —  lead,  arse- 
nic, etc., —  the  infectious  diseases  depend  on  noxious 
materials  that  enter  the  body.  But,  unlike  lead,  arse- 
nic, etc.,  the  poisons  which  produce  the  infectious  dis- 
eases are  associated,  not  with  a  few  well-known  material 
surroundings  and  inanimate  things,,  but  with  the  living 
activities  of  many,  often  unknown,  persons. 

The  little  we  know  of  how  to  achieve  high  health,  and 


98  THE  NEW  PUBLIC  HEALTH 

the  much  more  we  know  of  how  to  avoid  disease,  should 
be  taught  our  many  million  citizens.  This  huge  task 
requires  a  mechanism  so  huge  that  only  our  huge  public 
school  system  can  accomplish  it.2 

Efforts  in  the  second  direction  (for  specific  immuniza- 
tion) aim  to  "  fireproof "  our  bodies  against  disease, 
whether  those  bodies  be  "  palaces  "  or  "  hovels."  But 
such  fireproofing  can  as  yet  be  done  only  against  small- 
pox and  typhoid  fever.3 

Also,  just  as  the  general  public  will  not  fireproof 
literal  houses  against  literal  fire,  despite  large  fire  losses 
every  year,  so  the  general  public  will  not  fireproof  their 
bodies  against  infection,  even  against  smallpox.     One 

2  It  is  often  said  that  practicing  physicians  should  teach  health 
to  the  public.  In  one  sense  this  is  true.  Physicians  represent 
medicine,  and  medicine  deals  with  disease,  its  cure  and  its  pre- 
vention. But  practicing  engineers  might  as  well  be  drafted  to 
teach  geometry  as  practicing  physicians  to  teach  personal  hy- 
giene. Physicians  dealing  with  their  own  patients,  or  even 
lecturing  or  writing  on  these  subjects,  do  much  good.  Such  work, 
however,  is  but  a  drop  in  the  bucket,  reaching  only  a  fraction 
of  the  public  and  generally  just  that  fraction  which  needs  it 
least.  There  are  over  100,000  practicing  physicians  in  America. 
They  have  not  time,  training,  organization,  or  authority  for  the 
sort  of  teaching  that  will  really  reach  all  citizens;  the  public 
school  system  has  all  four,  and  nearly  a  million  teachers  to  do  it 
with. 

Medicine  must  furnish  the  facts  that  are  to  be  taught,  but 
it  is  quite  impossible  that  practising  physicians  should  do  the 
teaching. 

3  The  immunity  possible  against  diphtheria  through  protective 
doses  of  diphtheria  antitoxin,  is  too  short-lived  for  general  con- 
tinuous application  to  all  citizens. 


INDIVIDUAL  DEFENSE  99 

hundred  years  of  vaccination  has  left  us  with  only  30 
per  cent,  of  children  under  16  years  of  age  protected 
against  smallpox.  We  shall  be  lucky  if  10  years  of 
antityphoid  inoculation  finds  us  with  10  per  cent,  of 
adults  protected  against  typhoid.  In  the  absence  of 
compulsory  laws,  rigorously  enforced,  immunization 
must  remain  a  task  of  systematic  education,  reaching 
every  one,  and  this  task  also  only  the  public  school  sys- 
tem can  properly  perform. 

Efforts  in  the  third  direction  aim  to  shut  out  all  poi- 
sons, including  all  infections,  from  all  bodies,  whether 
these  bodies  be  palaces  or  hovels,  on  the  principle  that 
as  no  dwelling,  palace  or  hovel,  can  burn  if  fire  do  not 
reach  it,  so  our  bodies,  good,  bad,  or  indifferent,  cannot 
be  destroyed  by  disease  if  the  causes  of  disease  be  shut 
out  from  them.  To  abolish  literal  fire  from  literal 
dwellings  is  impracticable,  for  fire  is  too  useful  for  such 
abolition.  Disease  serves  no  useful  purpose,  and  its 
abolition  is  the  only  reasonable  goal. 

The  exclusion  of  the  poisons  of  disease,  infectious  or 
non-infectious,  from  the  body,  is  the  most  successful 
preventive  measure  we  have  at  present  against  most  dis- 
eases that  are  preventable  at  all.  The  methods  should 
be  taught  to  every  citizen ;  and  for  this  again  the  public 
school  system  alone  is  able.  Public  health  experts  must 
supply  the  facts ;  it  is  quite  impossible  that  they  should 
do  the  teaching.4 

4  Of  each  1,000  school  children  450  leave  school  at  the  end  of 
the  6th  grade  work,  450  leave  at  the  end  of  the  8th  grade.     The 


100  THE  NEW  PUBLIC  HEALTH 


"  Dodging  infection  "  rests  on  simple  principles,  al- 
ready outlined.  The  one  essential  is  to  exclude  from 
entrance  to  the  body,  matter  from  infectious  bodies,  i.e., 
in  briefest  practical  form,  to  exclude  from  the  body, 
usually  from  the  mouth,  the  infected  discharges  of 
others? 

To  do  this  requires,  first,  the  ability  to  recognize  in- 
fectious persons;  and,  second,  the  skill  to  avoid  their 
discharges.  But  we  cannot  teach  the  general  public, 
half  of  them  children,  to  recognize  infectious  persons. 
If,  then,  we  broaden  the  rule  and  teach  avoidance  of 
discharges  of  all  sick  persons,  whether  infectious  or  not, 
we  ignore  those  persons  who  are  infectious  without  being 
sick.  Hence,  for  the  non-medical  citizen,  the  rule  must 
run:     Exclude  all  discharges  of  all  persons  from  all 

remaining  100  enter  the  high  school;  but  only  50  graduate. 
Ten  out  of  the  thousand  enter  the  University;  5  graduate.  We 
now  teach  in  the  earlier  grades  theoretical  anatomy  and  theoreti- 
cal physiology,  intending  thus  to  form  foundations  for  later 
practical  information.  Since  90  per  cent,  of  children  leave  at  or 
before  the  8th  grade,  this  90  per  cent,  receive  the  theoretical 
information  only;  they  never  learn  its  practical  use  at  all. 

This  system  needs  inversion.  We  should  teach  the  practical 
parts  of  hygiene  and  of  avoidance  of  disease  to  the  100  per  cent, 
of  children,  i.e.,  not  later  than  the  6th  grade,  leaving  the  the- 
oretical parts  for  the  10  per  cent,  that  take  the  higher  courses. 

s  Plague,  malaria,  yellow  fever,  typhus  are,  in  most  cases,  the 
results  of  bites  of  insects  infected  from  infectious  bodies.  The 
principle  is  the  same  although  the  modes  of  transmission 
differ. 


INDIVIDUAL  DEFENSE  101 

bodies,  especially  the  mouth.     But  this  is  by  no  means 
so  easy  as  it  sounds. 

CONTACT-INTECTION- 

The  mouth-discharges  of  our  associates  are  constantly 
entering  our  bodies  in  the  form  of  mouth-spray,  of 
sputum,  and  of  smears  on  various  things,  but  chiefly  by 
smears  on  hands. 

Mouth-spray  consists  of  tiny,  often  microscopic,  drops 
of  liquid  from  the  mouth,  thrown  out  in  sneezing, 
coughing,  shouting,  singing,  and  speaking,  but  not  in 
quiet  breathing.  The  larger  ones  can  be  seen,  if 
watched  for,  and  they  can  be  felt  falling  upon  the  face 
during  close  face-to-face  conversations.  Talk,  or  sing, 
or  shout,  or  cough,  or  sneeze  against  a  mirror  two  feet 
distant,  and  count  the  drops  that  strike  it.  Then  pic- 
ture to  yourself  what  happens  at  "  teas "  and  "  so- 
ciables " ;  at  meals,  with  lively  conversation  going  on ; 
at  school ;  at  church.  Think  also  of  what  happens  when 
cooks  or  waiters  talk  while  preparing  food,  cough  while 
laying  tables,  or  sneeze  while  wiping  dishes. 

This  distribution  of  mouth-spray  cannot  be  prevented 
unless  all  wear  masks,  as  modern  surgeons  do  when  oper- 
ating. 

But  the  intaking  of  mouth-spray  may  be  avoided 
somewhat  by  avoiding  close  face-to-face  conversations, 
as  by  sitting  side  by  side  or  far  apart ;  its  distribution 
to  others  by  coughing  or  sneezing  always  into  a  hand- 
kerchief, etc.     Often,  of  course,  the  cough  or  sneeze 


102  THE  isTEW  PUBLIC  HEALTH 

comes  too  quickly  or  the  hands  are  already  full.  It  is 
true  that  the  head  may  be  turned  aside ;  but  often  this 
spares  the  person  in  front  at  the  expense  of  others,  and, 
while  coughing  or  sneezing  into  the  hand  prevents  the 
mouth-spray  from  flying  wide,  the  spray  goes  to  the  hand 
and  the  hand  itself  passes  it  on  to  other  persons 
later. 

There  is  no  practical  method  of  avoiding  all  mouth- 
spray  of  associates,  except  not  to  have  associates ;  but  the 
amount  of  exchange  may  be  diminished  by  the  above 
precautions. 

Sputum,  through  the  spitting  habit,  falls  upon  floors, 
steps,  sidewalks.  That  these  deposits  dry  and  blow 
about  as  dust  is  the  least  of  the  dangers,  especially  out 
of  doors,  for  sunlight  and  drying  disable  most  disease 
germs.  Sputum  follows  a  much  more  important  route 
leading  to  mouths,  and  this  route  is  followed,  not  when 
the  sputum  has  become  dry  and  dusty,  but  while  it  is 
still  fresh  and  moist, —  while  disease  germs  which  may 
be  in  it  are  still  living.  This  route  is  by  way  of  shoes, 
directly  into  houses.  There,  wiped  off  on  carpets,  it 
awaits  the  creeping  baby ;  it  smears  itself  on  the  baby's 
fingers;  and  they  carry  it  directly  into  his  mouth. 
Also,  the  owner  of  the  shoes  uses  his  fingers  in  remov- 
ing shoes,  and  then,  too  often,  the  owner's  fingers,  just 
like  the  baby's,  enter  the  mouth  unwashed.  The  value 
of  anti-spitting  ordinances  thus  becomes  apparent. 

But,  after  all,  hands  are  the  great  route  of  exchange, 
and    hands    furnish    the    great    route    for    bladder, 


INDIVIDUAL  DEFENSE  103 

bowel  and  other  discharges,  as  well  as  for  nose  and 
mouth.6 

From  birth  to  death  those  universal  tools,  our  hands, 
go  to  our  mouths  incessantly;  from  birth  to  death  we 
use  them  for  every  other  purpose  also.  Hands  encoun- 
ter all  the  discharges  of  the  body  many  times  a  day; 
and  if  not  scrupulously  washed  on  every  such  occasion, 
they  carry  these  discharges  to  everything  they  touch, 
including  other  hands,  which  go  to  other  mouths.  The 
very  handkerchiefs  we  advocate  to  cough  or  sneeze  or 
blow  our  noses  into,  transfer  these  same  discharges  to 
our  fingers,  the  next  time  that  we  use  them.7  Then  we 
shake  hands  with  others,  or  feel  the  baby's  new  tooth. 

Visits  to  toilets,  unless  followed  at  once  by  careful 
hand-washing,  mean  similar  transfer  of  the  toilet  dis- 
charges as  well,  particularly  amongst  children,  who,  re- 
member, form  nearly  half  the  population. 

The  common  drinking-cup  and  the  common  drinking- 
pail  are  bad  because  they  help  to  exchange  mouth-dis- 
charges ;  the  roller-towel  is  worse,  especially  when  used 
for  half-washed  hands,  because  then  it  helps  to  exchange 
all  the  bodily  discharges ;  but  the  unwashed  hands  them- 
selves are  worst  of  all,  because  the  discharges  they  carry 
are  undiluted  and  fresh  and  moist  and  warm.     When 

s  Hands  do  not  carry  infectious  diseases  only.  They  are  the 
chief  routes  by  which  lead  is  carried  to  mouths  in  lead-poisoning, 
and  are  also  an  important  factor  in  phosphorus  poisoning. 

7  It  has  been  suggested  that  the  left  hand  should  be  used  for 
handkerchiefs,  thus  leaving  the  right  hand  clean  so  far  as  these 
discharges  are  concerned. 


104  THE  NEW  PUBLIC  HEALTH 

strangers  enter  a  household,  they  add,  through  mouth- 
spray  and  hands,  their  discharges  to  the  general  house- 
hold stock ;  and,  in  this  way,  harvesting  help,  threshing 
crews,  etc.,  introduce  infectious  disease  into  numerous 
rural  families  and  communities  every  year. 

Within  the  purview  of  the  private  citizen  at  home, 
discharges  are  also  exchanged  somewhat  through  things 
soiled  by  mouth-spray  and  hands,  as  well  as  directly. 
Thus  are  contaminated  dishes  in  laying  the  table,  bread, 
cake,  etc.,  also  pillow-cases  and  sheets  which  are  soiled 
by  mouth  or  other  discharges  from  the  body.  The  list 
of  the  things  which  may  carry  such  discharges  is  too 
long  for  itemizing  here;  but,  in  general,  such  things 
do  not  form  really  very  important  routes  of  transfer, 
except  when  the  discharges  are  considerable  in  quantity 
and  while  the  discharges  are  fresh  and  moist.  Once 
dried  on  clothing,  mouth-spray,  for  instance,  is  not 
readily  set  free,  and  when  it  is  dry,  infection,  if  pres- 
ent, dies  out  with  fair  rapidity.  Just  as  the  main  pub- 
lic routes  of  discharges  from  the  community  to  the  fam- 
ily are  public  water  supplies,  public  food  supplies,  pub- 
lic milk  supplies,  and  public  outdoor  flies,  so  the  main 
private  routes  within  the  family,  apart  from  mouth- 
spray,  sputum,  and  hands,  are  private  water  supplies, 
private  food  supplies,  private  milk  supplies,  and  private 
indoor  flies.  Public  supplies  may  or  may  not  bring  dis- 
charges with  them  to  the  family;  once  they  enter  the 
family,  they  pretty  surely  receive  the  family  discharges 
from  the  family  itself.     So  also  with  the  private  sup- 


INDIVIDUAL  DEFENSE  105 

plies  of  the  same  things;  the  family  well  may  or  may 
not  be  dosed  with  the  family  discharges;  the  family 
drinking-pail  or  pitcher  almost  always  is;  the  family 
cow  may  or  may  not  contribute  discharges  to  the  family 
milk-pail,  but  the  family  milker  practically  always 
does ;  8  and  later,  within  the  family,  the  family  milk- 
pitcher  receives  the  family  mouth-spray.  The  family 
food,  before  and  even  after  cooking,  is  subject  to  similar 
contamination.  The  family  flies  moving  from  the  out- 
door toilet,  unless  it  be  fly-proof,  or  from  indoor  spit- 
toons or  slops  to  food,  aid  in  the  same  exchange.9 

To  know  these  dangers  means  half  the  battle  won. 

s  If  a  milker  talks  or  sings  or  coughs  or  sneezes,  using  a  wide 
mouth  pail,  his  mouth  discharges  enter  the  milk.  If  he  milks 
with  unwashed  hands,  all  his  discharges  enter  the  milk  also. 

9  A  curious  perversity  of  human  nature  makes  us  attach  un- 
due importance  to  many  possible  but  unimportant  routes  of  dis- 
charges, like  telephone-receivers,  dirty  money,  the  licking  of 
postage  stamps,  etc.,  while  we  neglect  the  commonplace,  really 
important  routes,  acting  daily  and  everywhere,  above  outlined. 

An  example  of  the  same  thing  is  seen  in  the  great  anxiety  ex- 
pressed concerning  meat  as  a  route  of  infection.  It  seems  to  be 
remembered  but  seldom  that  meat  is  almost  always  cooked,  i.e., 
it  almost  always  automatically  receives  the  very  treatment  we 
solicitously  prescribe  for  blocking  infection  through  milk  and 
through  water.  Meat-inspection  is  wholly  proper,  to  secure  good 
meat,  and  to  prevent  the  robbing  of  the  consumer's  pocket  and 
the  consumer's  stomach.  But  all  the  meat-inspection  in  the 
world  could  not  reduce  our  ordinary  infectious  diseases  by  one- 
tenth  of  1  per  cent.  Meat,  as  food,  especially  cold  meat,  often 
carries  the  family  discharges,  but  disease  in,  or  discharges  at- 
tached to,  meat  from  its  sources  outside  the  family,  are  in  most 
cases  destroyed  by  cooking. 


106  THE  NEW  PUBLIC  HEALTH 

Against  infection  of  public  routes, —  public  water  sup- 
plies, public  food  supplies,  public  outdoor  flies,  and  pub- 
lic milk  supplies, —  the  private  citizen  should  not  need 
precautions,  for  these  the  community  itself  should 
guard.  But  if  he  need  them,  the  private  citizen  has 
against  such  public  routes  two  powerful  weapons:  (a) 
exclusion  from  his  premises  of  the  infected  material, 
and  (b)  cooking.  Eoods  are,  of  course,  usually  cooked, 
even  in  ordinary  life ;  water  may  be  boiled,  milk  heated, 
and  if  flies  cannot  be  excluded,  the  food  they  contami- 
nate can  be  rejected  or  cooked  again. 

The  public  routes  of  infection  are  not  difficult  for 
the  citizen  to  guard  against,  however  wearisome  that 
guarding  may  be ;  the  real  difficulty  is  with  the  private 
routes,  those  routes  of  contact  that  carry  infection  within 
the  family  and  also  within  the  school,  the  office,  the 
workshop,  the  factory.  We,  individually  or  collec- 
tively, may  abolish  in  time  the  common  drinking-cup 
and  common  roller-towel,  but  no  one  can  ever  abolish 
mouth-spray  or  hands  throughout  the  race.10 

It  is  true  that  by  education  ll  we  may  greatly  affect 

10  One  hundred  million  mouths,  served  by  200,000,000  hands, 
receive  300,000,000  meals  in  America  daily.  But  these  hands 
are  not  as  important  as  are  the  hands  that  handle  the  meals  in 
preparation;  moreover,  hands  go  to  mouths  far  more  often  be- 
tween meals  than  during  them. 

ii  The  following  rules  prepared  for  use  in  the  public  schools 
at  the  request  of  County  Superintendent  Geo.  S.  Selke,  Benton 
County,  Minnesota,  indicate  the  main  points  to  be  taught  con- 
cerning protection  from  infectious  diseases  in  the  schools.  They 
indicate  also  pretty  closely  what  can  be  done  in  the  home  and  for 


INDIVIDUAL  DEFENSE  107 

personal  conduct,  but  to  leave  the  abolition  of  infection 
in  ordinary  life  to  the  personal  conduct  of  all  sorts  of 
people,  half  of  them  children,  would  be  as  wise  as  to 

this  reason  they  are  inserted  here.  (Now  printed  and  distributed 
to  Minnesota  Schools  by  the  State  Department  of  Education.) 

Placard  for  Schools 
The  germs  of  infectious  diseases  are  in  the  discharges  of  in- 
fectious persons.     Infectious  diseases  are  "  caught "  from   infec- 
tious  persons   simply   by   taking  into   the  mouth   some  portion, 
usually  very  small,  of  their  infected  discharges. 

The  Great  Rules  of  Prevention  in  Schools 

1.  Exclude  from  school  all  infectious  persons,  thus  excluding 
all  infectious  discharges. 

2.  Since  infectious  persons  may  enter  school  at  times  despite 
the  greatest  vigilance,  restrict,  so  far  as  possible,  the  scattering 
of  any  discharge  of  any  person  at  any  time  in  school.  (This  will 
also  train  the  children  to  restrict  their  discharges  out  of  school 
and  in  after-life.) 

a.  Mouth  discharges  are  transferred  directly  to  and  taken  di- 
rectly from  drinking-cups,  towels,  pencils,  chewing-gum,  whistles, 
etc.  Mouth,  nose,  bladder,  and  bowel  discharges  are  transferred 
directly  to  hands  many  times  daily.  Hands  go  to  mouths  many 
times  daily;  therefore  — 

Provide  individual  drinking-cups,  individual  towels,  individual 
pencils,  individual  modeling-clay,  individual  modeling-sand,  etc. 
( There  should  be  a  sign  in  every  school,  "  Wash  your  hands  after 
every  visit  to  a  toilet.") 

b.  Sputum  (spit)  or  other  discharges,  deposited  on  floors, 
sidewalks,  etc.,  are  picked  up  by  shoes  and  so  carried  into  homes. 
When  handling  shoes  (putting  on,  taking  off,  etc.),  discharges 
are  transferred  to  hands,  which  go  to  mouths,  or  touch  things 
that  go  to  mouths.     Therefore  — 

Avoid  depositing  discharges, —  sputum,  etc., —  on  floors,  side- 
walks, or  elsewhere  where  other  people  may  step  on  them. 


108  THE  NEW  PUBLIC  HEALTH 

trust  the  destruction  of  infection  in  a  water-borne  ty- 
phoid outbreak  to  the  boiling  of  the  water  by  private 
citizens. 

c.  Mouth-spray  is  thrown  out  in  talking,  singing,  coughing, 
sneezing,  etc.,  therefore  — 

Avoid  throwing  mouth-spray  into  other  people's  faces  by  avoid- 
ing close  face-to-face  conversation,  face-to-face  recitations,  face- 
to-face  singing-exercises,  etc.  Cough,  sneeze,  etc.,  into  a  handker- 
chief always. 

d.  The  air  of  a  schoolroom  in  use  necessarily  receives  mouth- 
spray  into  it  in  talking,  reciting,  etc. 

e.  Bladder  and  bowel  discharges  are  carried  by  flies  when  flies 
can  get  at  them.  During  early  autumn  and  late  spring  or  sum- 
mer sessions,  flies  may  carry  these  discharges  from  toilets  to 
children's  lunches,  etc.,  therefore  — 

Make  toilet-vaults  fly-proof.  Provide  springs  or  weights  to 
automatically  close  toilet-doors,  and  fly-screens  for  toilet-windows. 

f.  Three  things  destroy  comfort  and  success  in  school  work: 
Temperature  too  high;  Atmosphere  too  dry;  Air  not  in  motion. 
Also,  no  child  can  work  well  in  a  poorly  lighted  room;  but  do 
not  imagine  that  good  lighting,  good  heating,  and  good  ventila- 
tion will  prevent  spread  of  infection  if  infectious  persons  gain 
entrance.  No  school  is  a  sanitary  school  if  the  children  ex- 
change their  discharges  without  restriction ;  but  only  those  schools 
where  infectious  persons  are  watched  for  and  excluded  are  safe 
schools,  therefore  — 

Note  daily  the  general  state  of  health  of  each  child.  No  child 
who  shows  any  decided  change  from  the  usual  for  that  child, 
especially  fever,  headache,  sore  throat,  stomach-ache,  or  general 
dumpishness,  should  attend  school  until  seen  by  a  physician. 
This  rule  permits  early  detection  of  infectious  children.  It  also 
excludes  children  who  should  be  excluded  for  their  own  good, 
even  if  non-infectious. 

g.  Children  showing  defective  vision,  hearing,  breathing,  etc., 
should  be  referred  to  the  principal,  superintendent,  or  school 
board  for  action. 


INDIVIDUAL  DEFENSE  109 

All  health  officers  know  that  adults  in  large  propor- 
tion will  not,  and  many  children  cannot,  boil  the  water. 
Moreover,  the  law  (in  Minnesota)  now  recognizes  that 
the  community  has  no  right  to  supply  water  of  such  a 
kind  that  the  consumer  must  protect  himself  against  it. 
This  principle  should  be  extended,  so  that  the  commu- 
nity is  held  responsible  for  infection  carried  by  any 
public  route, —  food,  milk,  or  flies, —  as  well  as  by  pub- 
lic water.  Some  day  the  equally  logical  step  should 
follow, —  the  holding  of  the  community  responsible  for 
all  infectious  diseases,  by  whatever  routes  they  travel, 
including  contact.  The  community,  thanks  to  modern 
science,  can  abolish  the  sources  of  all  infectious  diseases ; 
and  once  the  sources  are  abolished,  the  diseases,  being 
non-existent,  cannot  travel  by  any  route,  even  by  con- 
tact. 

The  simple  fact  is,  that  the  private  citizen  in  his  own 
home  can  protect  himself  against  public  routes  of  dis- 
charges as  just  outlined  and  from  the  family  discharges 
to  some  extent;  but  the  moment  he  leaves  home  and 
enters  into  relations  with  the  general  public,  his  indi- 
vidual control  is  at  an  end.  He  cannot  guard,  generally 
he  cannot  even  ascertain,  the  sources  or  routes  of  the 
water,  milk,  food,  or  flies  he  must  encounter.  Above 
all,  he  cannot  guard  the  sources  or  routes  of  the  dis- 
charges furnished  by  the  persons  he  necessarily  meets. 
His  children  go  to  school,  compelled  directly  by  the  law 
to  do  so,  and  there  they  share  discharges  which  no  per- 
sonal defense  through  conduct  can  wholly  avoid.     He 


110  THE  NEW  PUBLIC  HEALTH 

goes  himself  to  work,  compelled  indirectly  by  the  law 
to  do  so,  and  there  he  shares  discharges  which  he  can 
little  or  not  at  all  control.  Only  the  community  can 
exclude  infection  from  the  public  routes  of  discharges, 
water,  milk,  food,  and  flies;  but  also  only  the  commu- 
nity can  exclude  infection  from  the  private  routes  of 
discharges  grouped  under  "  contact  "  ;  for  only  the  com- 
munity can  exercise  such  control  over  those  already  in- 
fected as  to  prevent  them  distributing  their  infection. 

Of  course,  the  exchange  of  discharges  already  out- 
lined, however  inevitable,  is  harmless  unless  and  until 
infected  discharges  enter  into  the  exchange.  The 
chances  of  encountering  infected  discharges  can  be  ap- 
proximated somewhat  from  the  supposition  that  daily 
there  goes  at  large,  unknown,  say  one  infective  person 
in  each  500  of  the  population.  Hence,  he  who  would 
defend  himself  from  infection  by  his  habitual  personal 
conduct  toward  his  associates  must  avoid  the  harmless 
discharges  of  499  uninfected  persons  in  order  to  avoid 
the  harmful  discharges  of  one  unknown  infected  person. 
(This  estimate  is  necessarily  a  guess,  and  it  does  not 
include  the  venereal  infections.) 

The  great  weakness  of  the  personal  defense  through 
conduct  is  this:  The  precise  moment  when  it  is  most 
needed  is  the  precise  moment  when  it  generally  fails. 
In  the  first  place,  the  mouth-spray  of  the  ordinary  well 
person  is  not  half  so  abundant  or  so  widely  scattered  as 
that  of  the  case  of  tuberculosis,  of  measles,  of  whoop- 
ing-cough, or  of  influenza,  for  these  are  just  the  diseases 


INDIVIDUAL  DEFENSE  111 

in  which  coughing  and  sneezing  are  prominent  symp- 
toms. The  bowel-discharges  of  the  ordinary  well  per- 
son are  not  half  as  likely  to  be  disseminated  as  those 
of  the  typhoid  or  dysentery  case,  for  these  are  just  the 
diseases  in  which  frequent,  abundant  liquid  stools,  often 
involuntary,  occur.  Again,  the  discharges  of  the  well 
person  are  handled  chiefly  by  that  well  person  himself ; 
the  discharges  of  the  sick  must  often  be  handled  by  asso- 
ciates unused  to  performing  such  services  for  others. 
Finally,  exactly  as  green  troops  forget  under  fire  all 
their  parade-ground  drill,  trip  over  their  own  feet,  and 
fire  into  the  ground  or  at  the  sun,  so  the  citizen,  how- 
ever carefully  he  may  have  practiced  a  well-thought-out 
system  of  avoiding  discharges  in  ordinary  life,  goes  all 
to  pieces  in  the  flurry  when  his  child  develops,  say,  scar- 
let fever.  Of  course,  it  is  true  that  untried  troops 
soon  recover  their  parade-ground  drill,  even  in  the  face 
of  the  enemy;  but  they  cannot  do  what  seasoned  troops 
can  do,  and  the  non-medical  citizen  can  seldom  protect 
himself  in  the  face  of  infection  as  the  trained  con- 
tagious-disease nurse  does,  the  physician,  or  the  epidemi- 
ologist. Nevertheless,  if  he  has  previously  known,  and 
practiced  even  crudely,  the  necessary  precautions,12  he 
is  in  a  much  better  position  to  defend  himself. 

12  It  is  a  fatal  fallacy  to  believe  in  "  general  cleanliness  "  as  a 
defense  against  infection.  It  is  not  the  "  general  cleanliness  "  of 
surroundings  that  prevents  infectious  diseases ;  it  is  the  "  specific 
cleanliness"  of  freedom  from  infected  discharges.  Scrubbed 
floors,  bright  pans,  neatness,  and  order  do  not  necessarily  in- 
volve,  usually   do   not   imply,   hands   free   of   discharges;    they 


112  THE  NEW  PUBLIC  HEALTH 

SUMMAKY 

The  whole  subject  of  public  health  divides  itself 
into  — 

1.  Securing  high  physical  development  and  efficiency. 

2.  Avoiding  disease. 

Of  the  former  we  know  little  of  practical  application 
to  the  general  population  except  in  infancy. 

Of  the  latter  we  know  much  of  cure,  but  little  of 
prevention,  except  in  the  environmental  diseases,  in  the 
poisonings,  as  from  lead,  arsenic,  alcohol,  etc.,  and  espe- 
cially in  the  infectious  diseases. 

Defense  against  environmental  diseases  and  the  non- 
infectious poisonings  is  largely  a  matter  of  trade  con- 
ditions and  of  avoiding  dangerous,  but  known,  non- 
living things  and  therefore  largely  of  legislation, 
inspection,  and  conduct.  Against  infectious  diseases, 
the  sources  being  infected  persons,  defense  is  essentially 
a  matter  of  precautions  against  those  persons.  The 
prime  difficulty  is  the  recognition  of  those  persons.  If 
they  are  not  recognized,  the  defense  becomes  a  matter 
of  guarding  against  all  persons. 

Defense  against  infection  may  be  divided  into  indi- 
vidual and  community  defense. 

Infectious  diseases  are  carried  by  four  main  public 

cannot  stop  mouth-spray.  A  gorgeous  uniform  no  more  shows 
ability  to  shoot  than  does  "  general  cleanliness  "  show  ability  to 
avoid  infection.  It  is  not  visible  dirt  that  hurts, —  mud,  ashes, 
coal-dust, —  but  the  usually  invisible  discharges  in  mouth-spray 
aDd  on  hands,  and  even  these  only  when  laden  with  infection. 


INDIVIDUAL  DEFENSE  113 

routes  —  water,  food,  flies,  and  milk ;  and  by  a  fifth  pri- 
vate route,  contact.  By  cooking  all  alimentary  sup- 
plies before  eating  them,  the  public  routes  may  be 
guarded  at  the  consumers'  end,  but  public  opinion  and, 
in  the  matter  of  water  supplies,  the  law  (in  Minnesota), 
rightly  demand  the  transfer  of  this  burden  of  protection 
to  the  producer. 

The  private  routes  of  contact  can  be  guarded  by  the 
individual  also,  but  only  by  a  ritual  so  elaborate  and 
covering  so  general  a  field  that  it  does  not  adequately 
meet  the  ordinary  conditions  of  the  ordinary  life  of  the 
ordinary  citizen,  especially  of  hard-working  fathers, 
hard-driven  mothers  and  young  children.  Contagious- 
disease  experts,  with  long,  patient  training  and  when 
dealing  with  known  infected  individuals,  generally  suc- 
ceed; the  ordinary  untrained  citizen  must  very  often 
fail. 

Notwithstanding  that  the  community  can  and  should 
assume  the  prevention  of  contact-infection  (by  exclud- 
ing infection  from  the  community  entirely),  in  addition 
to  the  care,  now  very  general,  of  the  four  public  routes, 
the  methods  of  personal  defense  should  be  well  known 
to  all ;  and  there  exists  no  means  of  teaching  them  com- 
parable at  all  with  the  great  public  school  system,  for 
that,  and  that  alone,  reaches  the  citizens  personally  and 
in  detail.  There,  in  simple  language,  all  that  is  useful 
can  be  readily  taught,  and  it  must  be  taught  in  the  sixth 
grade,  or  earlier,  to  reach  the  population  as  a  whole. 


CHAPTEK  X 
COMMUNITY  DEFENSE 

THE    PUBLIC    HEALTH    ENGINEER 

The  preceding  chapter  indicated  the  lines  of  personal 
defense  against  infectious  disease  which  are  available 
to  the  private  citizen  for  his  own  protection  through  his 
own  efforts. 

The  present  and  succeeding  chapters  will  deal  with 
community  defense, —  those  operations  which,  if  prop- 
erly conducted  by  communities  for  the  good  of  all, 
would  make  unnecessary  the  burdensome  efforts  of  indi- 
viduals to  protect  themselves. 

The  three  great  community  measures  for  the  abolition 
of  infectious  disease  have  been  listed  in  increasing  order 
of  efficiency  as  — 

1.  The  protection  of  all  public  routes  of  infection, 

public  water  supplies,  public  food  supplies,  public  milk 

supplies,  and  public  flies.     This  is  now  done  in  some 

places  to  some  extent.     Usually  it  is  but  half  done, 

chiefly  for  lack  of  proper  understanding  of  what  are  real 

protective  measures,  or  of  proper  organization  for  their 

execution;  too  often,  also  for  lack  of  proper  men  to 

carry  them  out. 

114 


COMMUNITY  DEFEXSE  115 

2.  The  physical  supervision  of  known  cases  of  infec- 
tious diseases.  This  also  is  often  now  attempted.  In- 
deed it  is,  on  paper,  the  most  developed  of  all.  But  its 
efficiency  is  cut  down  by  lack  of  reporting,  concealing 
of  cases  from  and  sometimes,  alas,  by  physicians,  etc., 
and  especially  by  lack  of  sufficient  trained  experts  in 
epidemiology  to  do  the  close-to-the-ground  daily  work. 

3.  The  sociological  supervision  of  all  infectious  per- 
sons, already  outlined  in  previous  articles. 

The  first  of  these  items  is  dealt  with  here. 

Tor  the  protection  of  the  public  routes  of  infection 
three  things  are  needed:  proper  physical  construction, 
to  exclude  infection ;  proper  physical  operation,  to  main- 
tain this  exclusion;  and  the  supervision  of  the  human 
factor, — "  the  man  behind  the  gun."  A  locomotive 
may  be  built  perfectly  and  be  kept  in  perfect  running 
order;  but  the  locomotive  engineer  himself  is  still  the 
soul  of  the  machine.  Perfect  physical  equipment  and 
perfect  physical  maintenance  of  public  utilities  related 
to  the  spread  of  disease,  are  enormously  important,  yet 
they  are  less  important  than  the  men  who  are  to  be  in 
actual  control  of  the  actual  operations.  Iso  better  illus- 
tration of  this  can  be  offered  than  the  fact  that  the  milk 
supply  from  tested  highbred  cows,  palatially  housed, 
scrubbed,  and  vacuum-cleaned,  has  many  times  carried 
disease  and  death  to  the  customers,  because  some  one 
man  engaged  in  handling  the  milk  conveyed  infection 
to  it  by  the  intimate  personal  contact  which  no  organiza- 
tion or  mechanism  can  wholly  avoid. 


116  THE  NEW  PUBLIC  HEALTH 

Some  of  the  worst  water  epidemics  we  have  ever  had 
were  due  to  the  human  factor  failing  at  the  critical  mo- 
ment. This  failure  of  the  human  factor,  which  is  a 
commonplace  in  accidents  by  rail  or  boat,  applies 
equally  to  all  branches  of  public  health,  although  the 
usual  belief  is  that  almost  any  person  is  good  enough 
to  conduct  public  health  work. 

The  reason  for  this  commonly  accepted  belief  is  prob- 
ably that  public  health  work  for  the  prevention  of  dis- 
ease, or  for  the  general  physical  advancement  of  the 
race,  is  often  confused  with  certain  measures  which 
make  merely  for  ease  or  comfort ;  and  it  is  human  na- 
ture to  look  down  upon  those  whose  services  minister  to 
our  comfort.  We  forget  that  by  our  slaves  we  rise  and 
by  our  slaves  we  fall.  Too  often  they  and  their  pro- 
cedures are  neglected  so  long  as  comfort  and  conven- 
ience are  supplied  by  them  without  too  much  trouble 
to  those  who  enjoy  the  fruits  of  their  labor. 

To  define  public  health  engineering  in  the  light  of  the 
new  public  health  principles,  it  must  be  denned  as  such 
work  as  deals  through  the  physical  construction  and 
operation  of  physical  surroundings  and  mechanisms 
with  (a)  the  prevention  of  disease  or  (b)  with  the  ad- 
vancement of  physical  bodily  welfare.  If  we  include 
also,  as  is  sometimes  done,  all  such  operations  as  con- 
duce, however  indirectly,  to  any  kind  of  "  racial  ad- 
vancement," we  must  add  all  engineering  works,  archi- 
tecture, street  paving,  acoustic  properties  of  public 
buildings,  the  size  of  doorways,  fire-escapes,  bridges, 


COMMUNITY  DEFENSE  117 

railways,  and  every  other  form  of  modern  artificial  sur- 
roundings, and  with  them  their  corollaries,  noise,  dust, 
the  smoke  nuisance,  etc. 

The  line  between  true  sanitary  measures  and  those 
for  securing  mere  comfort  or  convenience  must  be 
drawn  somewhere,  and  it  must  be  remembered  that  all 
"  racial  advances  "  are  by  no  means  advancements  of 
public  health.  The  railroads  are  of  great  sociological 
importance  to  the  race,  but  they  often  carry  disease 
faster  or  further  than  it  would  have  traveled  otherwise. 
Every  advance  which  leads  to  greater  prosperity  leads 
also  to  more  intermingling  of  people  and  to  wider  social 
relations  and  so  involves  a  wider  exchange  of  bodily  dis- 
charges. The  installation  of  a  public  water  supply  sys- 
tem adds  great  comfort,  convenience,  decency,  and 
physical  welfare,  but  it  also  provides  a  route  of  infec- 
tion theretofore  non-existing,  which  leads  directly  into 
every  home.  If  you  put  all  your  eggs  into  one  such 
basket,  you  must  watch  that  basket  A  sewerage  sys- 
tem, by  getting  rid  of  outdoor  toilets,  greatly  conduces 
to  decency,  comfort,  and  cleanliness,  and  even  obviates 
one  danger  of  disease  (carriage  of  toilet  discharges  by 
flies  from  the  outdoor  closet)  ;  but  it  also  concentrates 
all  those  discharges  into  one  foul  union  and  the  disposal 
of  this  often  endangers  other  communities,  and  there  is 
no  real  social  advance  in  transferring  the  burden  of 
infectious  disease  from  one  community  to  another  by 
passing  the  sewage  on  from  one  water  supply  to  an- 
other.    Hence  the  true  province  of  the  Public  Health 


118  THE  NEW  PUBLIC  HEALTH 

Engineer  is  not  the  mere  advocacy  and  construction  of 
great  engineering  enterprises,  but,  rather,  the  super- 
vision of  the  construction  of  such,  to  see  that  the  public 
health  harm  they  may  do,  if  the  public  health  view  be 
neglected,  is  properly  avoided,  so  far  as  physical  con- 
struction or  operation  may  avoid  it. 

The  Public  Health  Engineer  is  not  therefore,  or, 
rather,  should  not  be,  merely  what  the  popular  imagina- 
tion makes  him,  a  man  of  sewer  pipes  and  concrete ;  of 
water-meters,  manholes,  and  pumps.  The  New  Public 
Health  Engineer  will  be  a  man  keen  of  eye  to  see  those 
features  in  all  community  construction  work  which  may 
conduce  to  greater  exchange  of  discharges,  a  man  who 
knows  just  what  is  needed  for  prevention  of  disease  in 
such  ways,  and  therefore  can  both  provide  adequate 
precautions  and  at  the  same  time  avoid  unnecessary 
or  excessive  ones.  The  civil  engineer  has  been  de- 
fined as  he  who  can  do  for  $1.00  what  any  fool  can  do 
for  $4.00.  He  is  a  physical  economist.  He  insists  on 
physical  safety,  but  within  that  limit  knows  best  how  to 
achieve  the  needed  safety  without  undue  expenditure. 
The  Public  Health  Engineer,  dealing  with  water  sup- 
plies, sewage  disposal,  etc.,  does  just  this  thing.  He 
guarantees  sanitary  safety,  and  within  that  limit  he 
guarantees  it  for  less  money  than  the  ordinary  builder. 
Any  keen  student  of  infectious  diseases  can  generally 
see  the  grosser  faults  in  a  supply  which  permit  infec- 
tion. The  Public  Health  Engineer  is  a  specialist.  He 
sees  these  faults  very  much  more  quickly  and  surely ;  if 


COMMUNITY  DEFENSE  119 

they  are  intricate  he  has  the  skill  and  knowledge  to  dis- 
entangle them;  and  when  he  finds  them,  he  knows  how 
to  correct  them. 

The  Public  Health  Engineer  is,  or  should  be,  much 
more  than  this,  however.  He  is  the  only  public  health 
worker  whose  initial  professional  training  necessarily 
makes  of  him  a  business  man,  in  the  sense  of  an  ad- 
ministrator of  operations  on  schedule  time,  and  with 
economy  of  labor  and  expense.  Those  physicians  who 
make  good  administrators  in  this  sense  do  so  because 
they  learn  it  in  administration,  not  because  of  initial 
professional  training.  This  training  of  the  Public 
Health  Engineer  makes  him  also  the  best  man  to  super- 
vise maintenance  of  public  utilities,  as  well  as  to  con- 
struct and  equip  them.  Further,  the  absence  of  train- 
ing in  mechanisms  and  machinery  so  prominent  in  the 
training  of  most  health  officials,  makes  of  the  Public 
Health  Engineer  the  only  public  health  man  who  can 
deal  properly  with  the  many  mechanical  devices  for 
modern  handling  of  the  public  routes  of  infection,  on 
the  perfection  of  which  many  lives  often  depend.  The 
hypochlorite  plant,  the  mechanical  filter,  the  pasteuriz- 
ing device  are  machines.  However  well  a  physician 
may  understand  the  underlying  biological  principles,  he 
cannot  figure  the  pitch  of  a  cog-wheel  or  find  the  reason 
of  the  filter  "  loss  of  head  "  without  infinite  and  waste- 
ful effort,  if  at  all. 

The  Public  Health  Engineer  is  in  public  health  what 
the  surgeon  is  in  medicine,  the  "  man  of  his  hands," — 


120  THE  NEW  PUBLIC  HEALTH 

the  actual  operator.  Whatever  the  physician  may  dis- 
cover as  surgically  necessary  to  be  done,  it  is  the  sur- 
geon who  must  bring  his  skill  and  knowledge  to  bear 
upon  the  doing  of  it.  So,  although  the  epidemiologist, 
the  vital  statistician,  the  laboratory  man  must  usually 
determine  the  sources  and  routes  of  disease,  it  is  the 
Public  Health  Engineer  to  whom  all  must  turn  wherever 
and  whenever  those  sources  or  routes  are  to  be  put  out  of 
action  by  physical  construction  or  mechanical  device,  or 
when  economic  maladministration  of  public  utilities  is 
the  real  basis  of  the  trouble,  rather  than  a  physical 
condition. 

The  Public  Health  Engineer  is  not,  however,  as  a 
rule,  a  man  of  a  biological  turn  of  mind.  He  generally 
takes  vital  statistics  too  seriously  and,  lacking  medical 
knowledge,  interprets  vital  statistics  too  mechanically. 
His  own  units  of  weight,  volume,  and  measurement  are 
fixed  and  definite.  He  has  not  learned  to  scan  the  un- 
familiar units  of  disease,  each  by  itself ;  nor  is  it  likely 
that  as  a  class  engineers  ever  will.  The  spectacle  of  an 
engineer  advising  on  a  strictly  medical  problem  is  only 
less  sad,  if  less  sad  at  all,  than  that  of  a  medical  man 
advising  on  a  strictly  engineering  problem.  It  is  by 
co-operation  of  these  two,  each  perfect  in  his  own  field, 
but  aiding  the  other  with  real  understanding  of  the 
other's  problem,  that  well-balanced,  sane  advance  is 
made. 

So  far  as  the  five  great  routes  are  concerned, —  water, 
food,  milk,  flies,  and  contact, —  the  engineer  has  as  yet 


COMMUNITY  DEFENSE  121 

found  his  chief  field  in  dealing  with  water  supplies. 
Even  sewage  disposal,  so  far  as  it  is  a  sanitary  problem, 
has  as  yet  been  chiefly  considered  in  relation  to 
the  purity  of  water.  But  in  the  future  the  engineer 
must  also  deal  with  milk  supplies,  their  produc- 
tion, transportation,  pasteurization,  disinfection;  with 
the  great  fly  problem  and  its  chief  corollary,  the  safe 
disposal  of  human  excreta,  as  well  as  its  minor  corol- 
laries, garbage  and  manure  removal.  Finally,  perhaps 
chiefly,  he  must  deal  with  the  great  sociological  factors 
on  which  rests  contact  infection  in  public  meeting- 
places, —  the  factory,  the  shop,  the  church,  the  theater, 
the  school,  even  the  tenement  and  the  private  home. 
Above  all,  the  great  engineer  of  the  future  is  he  who 
will  see  with  trained  analytical  mind  and  act  with 
trained  administrative  ability  in  organizing  or  re-organ- 
izing not  one  but  a  dozen  of  the  many  factors  in  the 
modern  complex  of  society,  along  lines  which  shall  in 
themselves  redistribute  concentrated  forces  now  too 
closely  interwoven  for  mutual  good. 

But  there  must  be  more  public  health  in  engineering 
rather  than  more  engineering  in  public  health.  This 
little  book  will  have  failed  wholly  in  pointing  out 
the  real  essential  inside  truth  of  public  health  progress 
if  it  leaves  any  implication  that  infectious  diseases  can 
be  abolished  through  any  physical  or  mechanical  means. 
The  great  engineering  operations  of  the  day  have  an  im- 
portance to  mankind  much  greater  in  sociological  and 
economic  lines  than  in  public  health.     But  the  public 


122  THE  NEW  PUBLIC  HEALTH 

health  end  must  not  be  neglected,  even  though  we  recog- 
nize that  it  can  never  be  the  great  end  of  engineering, 
because  no  mere  guarding  of  such  routes  of  infection 
can  abolish  disease,  and,  if  it  could,  there  are  far  more 
direct,  drastic,  and  simple  measures  to  be  enforced  in 
other  directions  than  in  the  protection  of  public  utilities. 
Great  engineering  works  are  not  essential  to  the  abo- 
lition of  infectious  diseases,  but  great  engineering  works 
should  be  so  conducted  as  to  secure  what  reduction  in 
such  diseases  they  may.  The  ultimate  abolition  of  in- 
fectious diseases  rests  with  the  supervision  of  the  infec- 
tious individual,  and  no  mere  adjustment  of  surround- 
ings practical  for  the  race,  can  so  affect  his  conduct  as 
to  compel  that  conduct  along  proper  lines.  But  the 
public  health  engineer  through  housing,  organization, 
and  the  proper  construction  and  supervision  of  public 
utilities,  can  so  design  the  lines  of  least  resistance  that 
the  public,  who  generally  follow  these  lines,  will  find 
them  plain  and  smooth,  but  hedged  about  with  iron 
walls  of  safety. 

SUMMARY 

It  is  a  complete  misnomer  to  designate  as  a  sanitary 
engineer  him  who  merely  narrows  his  attention  from 
the  principles  and  practice  of  engineering  in  general  to 
the  application  of  these  principles  for  the  purpose  of 
constructing  water  supplies,  sewage-disposal  systems, 
rendering  of  garbage,  etc. 

A  man  is  not  a  sanitary  engineer  because  he  can  lay 


COMMUNITY  DEFENSE  123 

down  sewer  pipe  any  more  than  a  man  is  an  artist  be- 
cause he  can  lay  on  paint.  The  Public  Health  Engi- 
neer in  the  true  sense  is  he  who  has  acquired  so  wide  a 
view  of  modern  life,  of  its  mechanisms,  and  of  the 
physical  side  of  man's  environments,  that  he  can  see  and 
act  through  them  for  man's  physical  protection,  not 
merely  from  accident  but  also  from  disease.  He  does 
not  just  build  sewers.  When  he  builds  them,  he  builds 
them  as  part  of  the  great  fabric  of  modern  life.  His 
plans  are  not  merely  so  many  feet  of  pipe,  at  such  a 
price  per  foot ;  they  are  adaptations  and  applications  of 
great  fundamental  laws  to  the  physical  advancement  of 
mankind. 


CHAPTER  XI 
COMMUNITY  DEFENSE 

THE    PUBLIC-HEALTH    LABORATORY 

The  previous  chapter  discussed  the  relation  of  the 
Public  Health  engineer  to  the  protection  of  man  from 
disease,  through  the  construction,  operation,  and  direc- 
tion of  those  public  utilities  already  proved  to  be,  at 
times,  routes  of  infection. 

Some  day,  when  we  have  really  determined  the  con- 
ditions which  truly  promote  physical  well-being,  as  dis- 
tinguished from  those  which  merely  secure  escape  from 
disease,  the  Public  Health  engineer  will  find  larger 
functions  in  a  wider  field,  the  supervision  of  the  whole 
material  surroundings  of  man. 

The  present  chapter  attempts  to  set  forth  the  relation 
of  the  Public  Health  laboratory  man  to  the  same  two 
divisions, —  to  the  promotion  of  high  health,  on  the  one 
hand,  and  to  the  prevention  of  disease,  on  the  other. 
Like  the  Public  Health  engineer,  the  Public  Health 
laboratory  man  can  as  yet  contribute  but  little  to  the 
former,  and  for  the  same  reason,  i.e.,  because  so  little  is 
really  known  about  it.  Like  the  Public  Health  engi- 
neer, the  Public  Health  laboratory  man  deals  with  the 

124 


COMMUNITY  DEFENSE  125 

prevention  of  disease,  and  chiefly  with  the  prevention  of 
the  infectious  diseases.  Again,  like  the  engineer,  the 
laboratory  man  deals  in  part  with  routes  of  diseases, 
with  those  public  utilities  which  at  times  form  highways 
for  the  exchange  of  infected,  and  uninfected,  bodily  dis- 
charges. But,  unlike  the  engineer,  his  work  is  not  con- 
fined to  routes. 

The  Public  Health  laboratory  man,  like  the  epidemi- 
ologist, deals  also  with  sources,  i.e.,  with  the  infected 
person.  In  some  ways  he  goes  further  than  the  epi- 
demiologist, for  he  deals  with  the  infected  discharges 
themselves,  rather  than  with  the  person  who  discharges 
them;  and,  not  stopping  even  there,  he  deals  with,  in 
those  discharges,  the  very  principles  of  disease  itself, — 
the  individual  little  particles  of  living  matter  whose  ac- 
tivities in  the  human  system  produce  so  much  trouble 
for  us  all. 

This  dealing  intimately  with  the  ultimate  causes  of 
disease  is  a  fascinating,  dangerous,  peculiar  life-work, 
an  actual  herding,  and  handling  of  the  very  essences  of 
the  dreaded  plagues  of  old.  What  would  not  the  an- 
cient philosophers  and  sages  have  given  for  one  glimpse 
of  a  modern  Public  Health  laboratory  where  matter-of- 
fact  men  handle,  in  their  daily  matter-of-fact  routine, 
diphtheria  plants,  typhoid  plants,  tuberculosis  plants, 
etc.,  quite  as  a  student  farmer  handles  potatoes  or  corn  ? 

Because  the  little  plants,  or  animals  that  produce 
many  of  our  common  diseases  are  as  yet  not  actually 
known,  for  instance  those  of  scarlet  fever,  measles,  and 


126  THE  NEW  PUBLIC  HEALTH 

smallpox,  to  name  only  three,  the  Public  Health  labora- 
tory man's  chief  daily  duties  lie  with  those  diseases  the 
germs  of  which  are  known,  and  therefore  chiefly  with 
the  germs  of  typhoid,  diphtheria,  and  tuberculosis. 
These  furnish  the  bulk  of  his  work.  His  chief  services 
to  mankind,  in  the  temperate  zone  at  least,  consist  in 
the  aid  he  gives  in  recognizing  those  persons  who  are 
infected  with  one  of  these  three  germs  without  showing 
conclusive,  perhaps  any,  symptoms  of  their  presence. 
True,  he  can  and  does  perform  like  services  in  other 
diseases  whose  germs  are  known  —  such  as  anthrax, 
bubonic  plague,  cholera,  glanders,  leprosy,  etc. ;  but 
these  are  so  rare  as  to  form  only  a  flavoring  for  his  daily 
grist.  In  the  venereal  diseases,  also,  the  biological 
causes  are  known  and  can  be  recognized,  but  the  labora- 
tory man  must  await  the  development  of  the  growing 
public  demand  for  the  handling  of  these  diseases  on  a 
par  with  other  infections,  the  taking  up  of  these  great 
subjects  by  legislative  and  executive  authorities.  Until 
that  time  comes  the  laboratory  man  can  proclaim  his 
own  readiness  and  point  to  the  road,  but  he  can  do  little 
more.1 

With  the  routes  of  infection, —  water,  flies,  food, 
milk,  and  contact, —  the  laboratory  man  has  much  to  do, 
but,  again  and  for  similar  reasons,  he  deals  with  these 
routes,  in  the  temperate  zone,  chiefly  when  typhoid, 

i  Laboratory  tests  for  syphilis  and  gonorrhea  are  becoming 
recognized  of  late  as  Public  Health  laboratory  duties.  (See  New- 
York  Health  Department  and  others.) 


COMMUNITY  DEFENSE  127 

diphtheria,  or  tuberculosis  are  involved.  His  functions 
in  all  this  work  are  chiefly  analytic,  i.e.,  to  find  the  par- 
ticular water,  or  milk,  or  food  which  may  be  danger- 
ous ;  sometimes  to  detect,  if  he  may,  the  presence  in  them 
of  the  deadly  germ  itself. 

Unfortunately,  the  laboratory,  for  reasons  already 
offered  in  a  different  connection,  can  rarely  find  the 
germs  of  disease  in  water,  food,  milk,  or  flies. 
They  live  so  short  a  life  outside  of  the  human,  or  ani- 
mal, bodies  which  form  their  natural  growing-grounds 
that  the  laboratory  man  seldom  encounters  them  except 
in  the  body.  As  a  general  thing,  long  before  a  "  sam- 
ple "  of  water,  etc.,  arrives  at  the  laboratory,  the  dis- 
ease germs  it  may  once  have  held  are  dead  or  so  out- 
grown by  others  that  the  best  laboratory  methods  must 
necessarily  fail  to  find  them. 

So  little  is  this  understood  that  one  of  the  almost 
daily  happenings  in  every  laboratory  is  the  receipt  of 
water,  or  milk,  or  food  (flies,  fortunately,  are  not  often 
sent,  as  yet)  from  laymen,  even  from  physicians,  with 
the  request  that  they  be  searched  for  typhoid  or  diph- 
theria germs. 

But  consider!  Before  a  given  water  supply  has  at- 
tention called  to  it  as  a  source  of  typhoid  fever,  typhoid 
fever  cases  usually  must  have  developed  from  it.  Now, 
typhoid  fever  is  a  disease  which  does  not  develop  even 
its  very  first  symptoms,  until,  on  an  average,  two  weeks 
have  elapsed  after  the  germs  first  entered  the  body  from 
the  water  supply.     Usually,  another  week  passes  before 


128  THE  NEW  PUBLIC  HEALTH 

the  physician  is  called  and  perhaps  another  week,  more 
often  two  or  three,  before  the  sample  is  sent ;  therefore 
five  weeks  is  about  the  usual  time  which  has  slipped 
away  since  the  typhoid  germs  were  received  by  the  pa- 
tient into  his  body  from  the  water  supply,  before  the 
laboratory  man  receives  a  sample  from  it!  Now,  two 
weeks  is  probably  the  usual  maximum  for  typhoid  germs 
to  live  in  water,  even  if  the  water  be  stagnant  and  in  a 
dark  place.  When  it  is  heaving,  changing,  exposed  to 
the  sun  and  wind  and  current,  or  flowing  fast,  as  in  a 
river,  the  life  of  disease  germs  in  it  is  even  shorter,  and 
the  chances  of  their  dispersion  and  disappearance  by 
the  mere  physical  losing  of  themselves  are  almost  infi- 
nite. To  apply  laboratory  methods  to  finding  typhoid 
germs  in  the  ordinary  sample  of  water  taken  from  the 
suspected  supply  iive  weeks  after  the  cases  were  in- 
fected, would  be  like  shooting  at  the  place  where  a  flock 
of  ducks  had  been  five  weeks  before.  "  Hunting  for  a 
needle  in  a  haystack  "  is  discouraging  enough  in  itself, 
but  suppose  you  knew  the  needle  had  been  carefully 
removed  before  you  began  your  hunt ! 

The  laboratory  man  who  examines  water  does  so,  not 
in  the  hope  of  finding  typhoid  germs, —  he  does  not 
even  try  to  look  for  them,  as  a  rule, —  but  to  find  certain 
other  signs  of  excretory  pollution.  Curiously  enough, 
these  signs  are  often  of  more  real  value  to  Public 
Health  than  would  be  the  finding  of  the  typhoid  germs 
themselves,  were  that  practicable;  but  to  explain  how 
this  is,  would  be  out  of  place  here.     The  point  is  this : 


COMMUNITY  DEFENSE  129 

The  laboratory  tests  of  the  supposed  routes  of  infection 
in  any  given  case  are  made  by  methods  and  for  ends 
wholly  different  from  those  which  the  public  fondly 
imagines.  The  results  obtained  are  often  far  more  val- 
uable than  the  public  realizes  or  expects.  At  the  same 
time,  the  definiteness  of  these  results,  because  of  the 
facts  already  outlined,  are  far  inferior  to  those  ob- 
tained by  the  laboratory  examination  of  infected  per- 
sons —  in  brief,  the  information  obtained  by  the  labora- 
tory from  the  examination  of  "  samples  "  usually  re- 
quires elucidation  and  explanation  in  the  light  of  all 
sorts  of  other  information,  sociological,  meteorological, 
topographical,  geological,  etc.  Considered  thus,  the 
laboratory  work  is  nearly  invaluable,  but,  taken  by 
itself,  almost  as  nearly  worthless. 

The  happy  ignorance  displayed  by  those  who  think 
that  an  analysis  of  water,  or  milk,  or  food,  even  the 
most  thorough,  can  in  itself  and  by  itself  give  useful 
sanitary  information  is  equalled  only  by  the  joyful  con- 
fidence of  the  southern  darkey  in  a  rabbit's  foot.2 

The  true  position  of  the  laboratory  in  the  co-ordina- 
tion of  public  health  workers  which  will  rule  in  future 
organization,  has  been  achieved  but  seldom. 

2  The  British  Medical  Association  at  its  annual  meeting,  held 
1912,  passed  the  following  resolution :  "  That  this  con- joint 
meeting  of  the  sections  of  State  Medicine  and  Bacteriology  unani- 
mously desires  strongly  to  urge  that  no  opinion  as  to  the  quality 
of  a  water  for  dietetic  purposes  should  be  arrived  at  on  bac- 
teriological evidence  without  a  local  and  topographical  inspection 
of  the  sources  of  the  supply  made  by  a  competent  observer." 


130  THE  NEW  PUBLIC  HEALTH 

The  Public  Health  laboratory  man  of  to-day  has 
ceased  to  be  the  leader  in  public  health  endeavor  which 
he  once  was,  partly  because  he  has  been  swamped  with 
routine  work  in  the  lines  he  has  himself  developed,  but 
chiefly  because,  being  a  laboratory  man,  the  very  nature 
of  his  work  has  kept  him  indoors,  out  of  and  apart  from 
the  stirring  fields  of  human  life  in  being.  Perfect 
enough  in  his  own  technic,  he  has  perforce  lost  touch 
with  all  but  his  own  work,  and  other  lines  of  public 
health,  more  closely  involved  with  the  outer  world,  have 
passed  ahead  of  his. 

The  laboratory  man  of  the  future  will  get  out  into 
the  actual  daily  lives  of  the  people  and  communities  he 
serves.  He  will  know  outside  conditions  as  well  as 
those  in  the  laboratory.  He  will  work  more  closely 
with  the  engineer  and  the  epidemiologist.  He  has  his 
own  place  which  they  can  fill  no  more  than  he  can  fill 
theirs,  but  he  must  understand  their  work,  and  they  his, 
much  better  than  at  present. 

Moreover,  the  engineer  and  the  epidemiologist  suffer 
from  the  present  disassociation  of  the  laboratory  quite 
as  much  as  does  the  laboratory  man  himself.  Field 
work  moves  lamely,  oftentimes,  from  lack  of  laboratory 
knowledge,  just  as  laboratory  work  is  oftentimes  inert 
from  lack  of  field  knowledge.  During  the  last  few 
years  the  frequent  transfer  of  laboratory  men  into  the 
field  work  of  epidemiology  and  engineering  has  evolved 
a  set  of  men  who  recognize  this  fully.     But  it  is  not  by 


COMMUNITY  DEFENSE  131 

transferring  laboratory  men  to  other  fields  that  the 
laboratory  can  be  developed.  It  is  by  putting  the  lab- 
oratory itself  into  the  field  —  and  only  so  —  that  this 
can  be  accomplished. 

In  field  work,  and  in  research,  so  much  neglected  of 
late,  the  laboratory  man  will  find  his  future,  and  he  will 
not  deal  solely,  as  at  present,  with  infectious  diseases. 
True,  the  venereal  diseases  must  be  added  to  the  present 
list  of  those  for  which  routine  laboratory  facilities  are 
provided.  But  some  non-infectious  diseases  may  be- 
come preventable  diseases,  if  their  causes  are  discovered, 
and  the  Public  Health  laboratory  of  the  future,  acting 
in  conjunction  with  the  physiologist  and  the  pathologist, 
may  find  therein  usefulnesses  now  undreamed  of.  Fi- 
nally, as  we  slowly  learn  the  true  personal  hygiene  of 
food,  clothing,  sleep,  exercise,  etc.,  the  Public  Health 
laboratory  will  take  its  share  in  the  greatest,  but  least 
developed,  of  all  Public  Health  procedures,  namely,  the 
physical  advancement  of  the  race. 

SUMMAEY 

The  Public  Health  laboratory  finds  its  chief  functions 
to-day  in  the  detection  of  infectious  persons  (sources), 
and  in  the  identification  of  infected  things  (routes),  as 
means  to  the  end  of  abolishing  those  sources  and  block- 
ing those  routes.  The  average  public  health  laboratory 
has  been  swamped  with  routine,  cribbed,  cabined,  and 
confined  until  useful  research  has  almost  died  out  and 


132  THE  NEW  PUBLIC  HEALTH 

real  knowledge  of  outside  conditions  has  been  lost.  The 
engineer  and  the  epidemiologist  have  progressed  fast 
and  far  by  active  contact  with  the  needs  of  the  outside 
world,  and  the  laboratory  can  attain  its  proper  future 
only  by  like  development. 


CHAPTER  XII 
COMMUNITY  DEFENSE 

THE    PUBLIC    HEALTH    STATISTICIAN 

In  the  development  of  the  new  public  health  princi- 
ples, the  laboratory  came  first.  It  dealt  with  the  causes 
of  disease  at  first  hand,  as  well  as  with  their  sources  and 
their  routes  of  transmission.  On  laboratory  findings 
all  modern  public  health  is  based,  although  in  practice 
the  laboratory  is  necessarily  limited,  for  daily  service, 
to  those  diseases  the  causes  of  which  are  known. 

But  in  its  earlier  work,  the  laboratory,  inheriting 
somewhat  the  environmental  teachings  of  the  older 
school,  paid  more  attention  to  routes  than  it  did  to 
sources,  especially  to  the  routes  constituted  by  (a)  water 
and  (b)  general  surroundings.  This  focused  attention 
on  (a)  sanitary  engineering  and  (b)  disinfection.  It 
was  in  the  earlier  laboratory  period  that  the  sanitary 
engineer  and  the  disinfector  developed  highly.  It  is 
true  that  the  engineer  deals  almost  solely  as  yet  with 
but  one  route,  water ;  and  that  therefore  his  efforts  neces- 
sarily relate  almost  solely  to  the  intestinal  infections, 
mainly   to    typhoid   fever.     Nevertheless,    so    valuable 

were  his  services  in  reducing  this  disease,  that  engineer- 

133 


134  THE  NEW  PUBLIC  HEALTH 

ing  work  was  hailed  at  one  time  as  the  solution  of  all 
public  health  questions.  Xow  the  epidemiologist  leads 
the  van,  because  he  deals  not  with  some  routes,  of  some 
infectious  diseases,  but  with  all  sources  of  all  infectious 
diseases. 

STATISTICS    AS    THEY    WILL    BE 

But,  through  the  work  of  the  laboratory  man,  the 
engineer,  and  the  epidemiologist,  has  for  long  been  heard 
a  still,  small  voice,  offering  a  framework  to  bind  them 
all  together  —  to  give  coherence,  correlation,  and  pro- 
portion —  to  outline  the  future,  as  well  as  to  record  the 
past,  and,  above  all,  to  direct  the  present.  This  was  the 
voice  of  the  vital  statistician.  Much  abused,  laughed 
at,  neglected,  he  is,  or  will  be,  guide,  map-maker,  intelli- 
gence department,  all  in  one ;  he  is,  or  will  be,  like  the 
cost-of-production  scientific  manager  of  modern  busi- 
ness, "  the  most  indispensable  man  on  the  staff." 

True,  his  professional  ancestors  were  helpless  old  gen- 
tlemen, raising  their  feeble  voices  in  very  feeble  chants. 
A  dry-as-dust  historian  of  the  wars  of  ancient  Greece 
could  lend  more  aid  to  a  modern  football  team  than  the 
old-time  statistician  furnished  to  public  health  en- 
deavors. Even  now  the  new  vital  statistician  is  scarcely 
yet  full-born.  Hardly  a  health  department  now  in  ex- 
istence collects  in  full  or  uses  to  full  advantage  one- 
tenth  the  information  that  it  really  needs.  (A  notable 
exception  should  be  recorded  here,  the  Richmond  (Va.) 
Health  Department  under  E.  C.  Levy.)     The  labora- 


COMMUNITY  DEFENSE  135 

tory  man  has  made  some  good  statistics  in  his  own  field ; 
so  has  the  sanitary  engineer  —  sometimes,  alas,  not 
wisely,  but  too  well ;  the  epidemiologist,  also,  from  sheer 
necessity :  but  the  new  vital  statistician  has  only  begun 
to  move.  When  he  does  move,  fully  equipped,  alert,  he 
will  systematize,  organize,  and  use  the  rich  data  so  far 
largely  wasted,  this  very  life-blood  of  public  health  en- 
deavor, accurate,  complete  information  concerning  the 
way  humanity  reacts  to  human  ills.  Internal  public 
health  organization  has  been  like  the  old-time  factory, 
full  of  good  workmen,  but  each  working  only  his  own 
line,  with  no  one  person  knowing  much  about  the  busi- 
ness as  a  whole.  At  the  end  of  the  year  the  business, 
drifting  along,  perhaps  showed  a  doubtful  profit,  per- 
haps a  loss,  but  so  long  as  bills  and  wages  were  somehow 
paid,  who  cared  ?  Public  health  requires  exactly  the 
kind  of  man  who  has  changed  the  face  of  business  in  the 
last  fifteen  years,  a  man  who  understands  all  parts  of 
it,  but  does  none  himself;  a  man  who  knows  costs  in 
each  department  in  proportion  to  production,  and  where 
to  cut  cost,  increase  production,  save  time,  unnecessary 
work,  and  waste  in  general ;  alas,  in  health  departments, 
a  man  to  stop  the  one-half,  now  done  uselessly  in  wholly 
wrong  directions  and  to  force  development  of  the  other 
half,  now  much  neglected  or  left  undone  completely. 

It  is  the  vital  statistician  who  must  do  this:  collect 
the  facts  and  set  them  forth  inexorably,  with  mathe- 
matical precision.  When  it  is  done,  our  health  depart- 
ments will  no  longer  use  up  $30,000  for  garbage,  with 


136  THE  NEW  PUBLIC  HEALTH 

the  probability  that  not  a  single  life  will  be  saved 
thereby,  while  spending  $12,000  on  all  other  health  de- 
partment efforts  combined.  Nor  will  a  health  depart- 
ment spend  for  terminal  disinfection  one-tenth  its  an- 
nual appropriation,  to  save  no  lives  at  all,1  while  using 
but  one-fiftieth  its  appropriation  for  tuberculosis,  which 
kills  five  times  as  many  people  as  all  the  diseases  usually 
"  disinfected  "  put  together. 

It  will  be  said :  "  You  are  confusing  vital  statistics 
with  health  department  finance ;  vital  statistics  deal  with 
deaths,  not  money."  Exactly  —  and  that  is  just  ex- 
actly what  is  wrong  with  them.  Vital  statistics  are 
now,  in  short,  not  vital;  they  deal  with  Death,  not  Life, 
with  the  "  finished  product  "  only  of  our  slack,  slipshod 
methods.  They  ought  to  deal,  not  merely  with  dead 
bodies,  but  who  they,  living,  were,  and  why  and  how 
they  died,  and  above  all  with  why  they  were  not  saved. 
Suppose  the  factory  manager  knew  at  the  end  of  the 
year  merely  his  total  product !  Suppose  that  even  this 
piece  of  information  related,  not  to  the  way  business 
went  last  year,  but  to  the  way  it  went  five  years  before. 
"  Historical  records,  and  mighty  poor  at  that,"  a  mod- 
ern public  health  man  said  in  bitter  scorn  of  the  sta- 
tistics of  a  neighboring  State.  The  modern  scientific 
manager  must  know  not  merely  the  total  product,  though 
he  must  know  that,  and  to  the  minute,  not  to  five  years 

i  In  tuberculosis,  where  terminal  disinfection  would  be  valu- 
able it  is  not  often  done.—  J.  A.  P.  H.  A.,  April,  1913,  p.  311, 
M.  N.  Baker. 


COMMUNITY  DEFENSE  137 

before;  he  must  know  also  all  about  the  product,  the 
kind,  the  quality,  the  cost,  and  why  it  is  not  better  for 
the  price.  The  modern  vital  statistician  must  know 
not  only  deaths,  but  why  the  health  department  is  not 
stopping  them ;  what  its  funds  are ;  how  they  are  spent 
or  wasted ;  what  work  is  being  done ;  how  much  of  value 
each  division  does ;  and  all  to  the  one  end  of  saving  life, 
not  to  the  end  of  stopping  nuisances,  removing  garbage, 
or  cleaning  streets  —  all  admirable  ends  no  doubt,  but 
not  life-saving  ends. 

But,  it  will  be  said,  "  Very  well,  but  you  are  wrong 
in  stating  that  Vital  Statistics  deal  with  Deaths.  They 
deal  with  more  than  Deaths  —  they  deal  with  Births 
and  Marriages  and  contagious  diseases  also."  "  Yes, 
nominally ;  but  to  what  useful  end  for  public  health  ?  "  2 

"  Birth  records  quite  often  affect  inheritance  of 
estates  in  later  years."  True,  and  very  useful  to  the 
inheritor  they  are  when  the  time  comes,  but  what  has 
that  got  to  do  with  saving  life  now  ?  Marriage  records 
also  are  invaluable  in  their  own  way,  but  they  do  not 
reduce  tuberculosis  one-tenth  of  a  tenth  per  cent.  Con- 
tagious disease  reports,  then?  Surely  they  are  impor- 
tant ?  Yes,  but  not  as  they  are,  too  often,  now  collected. 
Misleading  information  is  sometimes  worse  than  none  at 
all. 

2  Birth  records,  if  they  led  to  immediate  investigation  to  see 
that  the  child  was  cared  for  properly,  would  be  true  public  health 
data. 


138  THE  NEW  PUBLIC  HEALTH 


STATISTICS    AS    THEY   ABE 


The  best  way  to  show  what  public  health  vital  statis- 
tics as  they  are  to-day  mean,  or  do  not  mean,  is  to  give 
the  story,  true  to  life,  as  any  one  who  knows  will  quickly 
see,  of  the  very  basis  of  such  statistics,  the  actual  facts 
as  they  occur  amongst  the  people. 

Mrs.  Anybody  says  to  Mr.  Ditto :  "I  am  afraid 
Tommy  has  scarlet  fever ;  I  think  he  must  have  caught 
it  when  he  was  in  the  city."  "  Call  Dr.  A."  "  Yes, 
but  they  say  he  will  report  it,  if  it  is  scarlet  fever.  I'm 
nearly  wild  now  with  work.  When  the  children  are  at 
school  all  day  I  manage  somehow ;  with  you  and  the  chil- 
dren quarantined  at  home  for  a  month  I  should  go  in- 
sane. I'll  call  Dr.  B. ;  they  say  he  never  reports  any- 
thing. I'll  tell  the  neighbors  it  is  scarlet  rash.  That's 
not  a  lie.  It's  a  rash,  and  it  certainly  is  scarlet.  I'll 
let  the  children  go  to  school,  but  I'll  keep  every  one 
away  from  Tommy.  I'd  hate  to  think  any  other  child 
got  it  from  our  children,  but  I  guess  that  will  be  all 
right.  Tommy  is  not  very  sick.  Don't  go  telling  any 
one  he  is  sick.  I'll  tell  the  children  not  to,  either.  We 
don't  want  to  have  the  milkman  or  the  grocer  afraid  to 
call." 

So  Mrs.  Anybody  plans,  and  so  it  is  carried  out.  But 
her  heart  is  bigger  than  her  head,  and  her  plans  go 
strangely  awry. 

She  puts  Tommy  in  a  room  by  himself  and  runs  over 
to  a  neighbor's  for  an  egg  or  a  cup  of  flour.     When  she 


COMMUNITY  DEFENSE  139 

comes  back  the  other  children  are  lined  up  in  Tommy's 
room,  solemnly  inspecting  the  rash  he  proudly  demon- 
strates to  them.  Next  morning  Tommy  is  "  real  sick," 
and  after  breakfast  the  mother  puts  up  the  other  chil- 
dren's school  lunches  alternately  with  running  in  to 
Tommy's  room  to  give  him  water  or  to  hold  the  basin 
while  he  vomits  or  just  to  kiss  and  soothe  him. 

Poor,  loving,  hard-working  mother!  She  has  done 
this  same  through  all  the  ages,  this  taking  of  infected 
discharges  from  the  sick  child,  on  her  hands,  to  be  put 
later  in  the  other  children's  food.  No,  she  won't  kiss 
them  good-bye;  she  has  been  kissing  Tommy;  that  is, 
she  won't  kiss  any  but  the  smallest  one,  who  looks  near- 
est to  crying.  She  wipes  that  one's  mouth  with  her 
apron  before  she  kisses  it  —  she  does  not  wipe  her  own! 
Not  that  wiping  either  matters,  for  Tommy's  mouth 
discharges  are  already  in  the  lunch  the  little  one 
marches  out  with,  under  its  arm. 

About  10  a.  m.,  the  empty  house  and  the  wailing 
child  get  on  the  mother's  nerves.  So  she  calls  in  a 
neighbor.  "  Tommy's  sick.  I  want  to  go  to  the  store 
to  telephone  the  doctor.  It's  only  scarlet  rash.  I  won't 
be  gone  more  than  a  minute,  but  I'm  afraid  he'll  get 
out  of  bed  or  something.  Will  you  keep  an  eye  on 
him?" 

The  neighbor  comes  in,  the  baby  on  her  arm,  for  is  it 
not  scarlet  rash?  But  prudence  strikes  her  suddenly, 
and  she  sets  the  baby  on  the  floor  before  she  peeks  in  at 
Tommy.     "  Hullo!"     "  Hullo,    Mrs.    Neighbor!"    a 


140  THE  NEW  PUBLIC  HEALTH 

feeble  little  voice  replies.  She  steps  in  further,  leav- 
ing the  door  open  to  keep  an  eye  on  baby.  "  Well, 
Tommy,  how  do  you  feel  ?  "  "  ISTot  very  well/'  and  he 
begins  to  vomit.  She  snatches  a  basin,  holds  his  head, 
and  in  a  moment  surrenders  him  to  his  mother,  and 
then  takes  her  baby  hurriedly  home.  A  speck  of  vomit- 
spray  has  hit  her  hand.  She  did  not  notice  it.  The 
baby's  fingers  rest  on  it  a  moment,  before  it  is  dry;  a 
minute  later  the  baby  sucks  that  finger.  At  home  she 
sets  the  baby  down  and,  conscience-smitten,  changes  her 
dress  (she  does  not  wash  her  hands!)  and  thereafter 
feels  all  right  again  because  she  thinks  that  now  she 
can't  give  it  to  any  one,  even  if  it  is  scarlet  fever;  be- 
sides, the  doctor  said  it  was  scarlet  rash. 

Meantime,  Mr.  Anybody,  summoned  by  his  wife, 
hurries  home  in  terror,  finds  Tommy  still  quite  alive, 
growls,  fusses,  brings  in  some  wood,  pumps  a  little 
water,  and  then  steps  into  Tommy's  room,  "  just  inside 
the  door  for  a  minute,"  before  going  down-town  again. 
Tommy,  with  feverish,  flushed  face  and  heavy  eyes 
under  his  tousled  hair,  calls  feebly,  "  My  daddy,  my 
daddy  " ;  and,  of  course,  Mr.  Anybody  steps  to  his  bed- 
side to  pat  his  head  and  kiss  him,  before  hurrying  back 
to  business. 

That  night  Tommy  is  worse ;  sorrow  is  on  the  family 
in  earnest.  Next  morning  Tommy  is  much  better ;  the 
prayers  and  tears  of  the  night  before  are  forgotten ;  the 
mother,  weary  but  joyful,  lets  the  other  children  in  to 
see  him ;  "  just  for  a  minute  now,  but,  anyway,  he  is  so 


COMMUNITY  DEFENSE  141 

much  better,"  and  they  all  race  out  to  school,  shouting 
and  laughing. 

About  five  days  later,  Susan,  the  youngest,  is  not 
feeling  very  well  towards  evening,  vomits  during  the 
night,  is  delirious  next  morning,  with  sore  throat, 
swollen  neck,  and  rash ;  and  Dr.  B.  comes  again.  Seri- 
ous measures  are  taken.  The  other  children,  in  tears, 
are  spirited  away  to  a  cousin's  house  to  stay  lest  they 
should  get  it,  and  because  the  mother  can't  stand  the 
strain  of  nursing  the  sick  and  caring  for  the  well  also. 

Tommy  has  had  it  mildly,  and  by  this  time  is  up  and 
about,  wandering  disconsolately  through  the  empty 
house.  To  all  inquirers  the  mother  bravely  maintains 
that  Susan  has  only  the  scarlet  rash  and  tells  them 
Tommy  will  go  back  to  school  in  a  day  or  two.  "  I 
just  sent  the  other  children  away  because  they  were  so 
noisy,"  she  explains  guiltily,  wishing  very  earnestly 
that  it  was  really  so. 

Next  day  Susan  is  better.  (I  am  writing  this  — 
and  therefore  I  make  it  thus.  In  real  life,  poor  little 
Susan  often  dies,  instead.)  Every  one  is  cheerful 
again.  Tommy  is  sent,  very  unobtrusively,  to  school 
because  "  he  mopes  at  home,  without  a  soul  to  play 
with."  He  is  beginning  to  peel,  and,  in  a  day  or  two,  is 
in  much  demand  amongst  his  schoolmates,  presenting 
them  with  souvenirs  of  flakes  of  skin  they  treasure  as 
curiosities.  Not  that  these  scales  do  harm,  despite  the 
old  beliefs.  It  is  not  the  peeling,  which  everybody 
sees,  that  does  the  mischief,  but  the  unnoticed  slightly 


142  THE  NEW  PUBLIC  HEALTH 

red  sore  throat  that  Tommy  carries  with  him,  and  from 
which  he  infects  his  hands  (and  every  one  he  touches) 
and  shoots  out  infection  in  has  mouth-spray  as  he  chants 
his  lesson,  or  whispers  across  the  aisle,  or  sings  in  class. 

And  so  the  old,  old  story  works  itself  out  inexorably. 
One  of  the  other  children,  staying  at  the  cousin's,  de- 
velops a  slight  sore  throat.  Were  there  an  epidemiolo- 
gist at  hand,  posted  on  the  history  of  the  child,  to  scan 
the  enlarged  papillae  of  the  tongue,  note  the  large 
glands,  and  see  the  filmy  membrane  on  the  tonsils,  the 
case  would  be  recognized  as  scarlet  fever,  sine  erup- 
tlone,  i.e.,  without  a  rash.  But  as  it  is  "  it's  only  a 
sore  throat."  No  physician  sees  her,  because  the  cousin 
argues  thus :  "  If  it  were  my  child,  I'd  have  in  Dr. 
A.,  but  Mrs.  Anybody  wouldn't  thank  me  for  running 
up  another  bill  here,  unless  the  child  is  really  ill ;  she's 
having  Dr.  B.  now,  for  Susan,  twice  a  day.  I'll  wait  a 
day  or  two,  anyway." 

The  sore  throat  heals,  and  the  cousin  feels  she  made 
a  good  judgment.  But  meantime  the  sore-throat  girl 
has  been  sleeping  with  the  cousin's  little  girl,  and  she 
develops  it,  too,  but  it  also  passes  off.  Then  a  week 
later,  the  cousin's  little  girl's  school-chum,  in  a  different 
school  from  Tommy's,  has  scarlet  fever  proper.  Dr.  A. 
attends,  and  reports  it.  The  Health  Department  puts 
a  placard  up;  the  children  are  kept  out  of  school;  the 
father  is  kept  at  home;  the  whole  population  turns  its 
eyes  on  that  family  and  wonders  where  they  got  it. 
The  village  wiseacres,  over  the  village  bar,  remind  each 


COMMUNITY  DEFENSE  143 

other  of  the  slough  behind  the  house,  or  that  the  gar- 
bage from  the  family  was  never  removed  all  summer. 
They  say  the  well  is  shallow,  "  nothing  but  surface 
water,' '  or  the  house  is  damp,  or  too  much  shut-in  by 
trees,  or  any  other  fatuous  foolishness  that  enters  their 
empty  heads.  The  mayor  gives  out  a  statement  to 
"  allay  popular  excitement."  He  brands  as  malicious 
all  statements  that  scarlet  fever  is  rampant.  There  is 
but  one  "  sporadic  case,"  originating  no  one  knows  how. 
It  is  carefully  quarantined,  and  "  the  Health  Depart- 
ment believes  the  outbreak  is  well  in  hand  and  prac- 
tically stamped  out."  The  Women's  Club  demands  the 
fumigation  of  the  schools;  and  the  epidemiologist,  if 
only  he  were  present,  would  gaze  reflectively  at  Tommy's 
slightly  red  throat,  and  gnash  his  teeth,  and  swear.3 
Poor  Dr.  A.  who  only  did  his  duty,  is  blamed  for  all 
the  trouble;  and  Dr.  B.  keeps  mum.  When,  pres- 
ently, Dr.  C.  is  called  to  one  of  Tommy's  schoolmates,  he 
hesitates.  He  has  not  seen  much  scarlet  fever,  and  he 
thinks,  "  perhaps  it  is  scarlet  rash  —  whatever  that 
may  be."  He  attends  the  child  two  or  three  days,  and 
then  he  begins  to  ponder  whether  or  not  he  had  best  put 
the  responsibility  on  the  Board  of  Health ;  so  at  last 
he  calls  up  Dr.  D.?  the  Health  Officer.  But  Dr.  D.  has 
troubles  of  his  own.     "  Do  you  say  it  is  scarlet  fever  ?  " 

3  Editor's  Note. —  We  regret  the  epidemiologist  should  do  this, 
but  we  propose  to  give  the  facts,  no  matter  whom  they  hit.  Be- 
sides, we  do  not  blame  the  epidemiologist  much  under  the  cir- 
cumstances. 


144:  THE  NEW  PUBLIC  HEALTH 

"  Well,  I  don't  know.  I  want  you  to  go  and  see."  The 
H.  O.  is  perplexed.  He  does  not  want  the  reputation 
of  finding  a  second  case,  after  the  Major  has  stated  that 
there  is  only  one ;  so  he  tells  Dr.  C. :  "  If  you  report  it, 
I'll  placard  the  house,  but  I  don't  want  you  to  report 
it,  if  you  are  not  sure."  At  this  Dr.  C.  waits  a  day  or 
two  more,  but  finally  reports  it.  Meantime  a  week  of 
association  of  the  other  children  with  the  sick  one  has 
elapsed,  because  Dr.  C.  did  not  quite  know  the  finer 
points  in  recognizing  mild  scarlet  fever  early. 

By  this  time,  between  the  unconscious  activities  of 
Tommy  and  Susan,  who  are  back  at  school,  well  oiled 
by  Dr.  B.'s  advice,  to  keep  the  scales  from  showing,  and 
of  Susan's  sister  and  the  cousin's  little  girl  (none  of 
them  recognized  officially  as  scarlet  fever),  some  twenty 
or  thirty  children  in  the  two  schools  have  been  infected. 
Some  of  the  pupils  have  had  scarlet  fever  before  and  so 
escape  this  time.  In  others  the  disease  is  mild  and 
passes  unnoticed.  In  others  "  scarlet  rash  "  develops. 
But  several  develop  frank  scarlet  fever,  not  to  be  denied 
even  by  Dr.  B.  who,  to  give  him  credit,  has  begun  "  to 
get  a  little  scared,"  and  so  reports  one  or  two  well- 
marked  cases  to  relieve  his  conscience.  Two  or  three 
deaths  occur,  and  then  the  schools  are  closed,  but  not 
the  Sunday  schools,  or  churches,  or  private  sociables, 
or  moving  pictures,  and  so  it  drifts. 

Now,  see  how  all  this  affects  vital  statistics.  The 
Health  Department,  in  its  annual  statement,  gives  as 
the  first  case  that  school  chum  of  the  cousin's  little  girl. 


COMMUNITY  DEFENSE  145 

We  know  that  there  were  four  cases  before  that  — 
Tommy  and  Susan,  and  Susan's  sister,  and  the  cousin's 
little  girl  —  but  these  do  not  go  down  upon  the  books 
at  all.  The  Health  Department  adds  thirteen  more 
cases;  that  is,  all  those  cases  attended  by  Dr.  A.,  faith- 
ful, conscientious  man;  about  half  of  Dr.  B.'s  cases, 
those  he  had  after  he  "  got  scared  " ;  and  some  of  Dr. 
C.'s,  but  only  those  he  was  absolutely  certain  of,  not 
knowing  scarlet  fever  very  well.  Dr.  D.  had  no  cases, 
because,  being  health  officer,  the  mothers  felt  that  he 
would  have  to  report  them,  and  so  did  not  call  him. 

The  fact  is,  that  any  epidemiologist  would  find  that 
there  were  forty  cases,  but  the  books  show  fourteen. 

Then  consider  the  deaths.  Two  were  reported  prop- 
erly as  due  to  scarlet  fever.  But  one  of  Dr.  B.'s,  really 
scarlet  fever,  not  quarantined  while  ill,  is  reported 
"  acute  Bright's  disease,"  because  the  doctor  dare  not 
say  it  died  of  scarlet  fever  after  treating  it  a  month 
without  reporting  it.  It  is  quite  true  the  child  had 
Bright's  disease,  but  it  had  Bright's  disease  because  it 
had  scarlet  fever.  Another  dies  of  meningitis,  due  to 
middle-ear  infection,  the  result  of  scarlet  fever,  but 
being  meningitis,  this  death  also  goes  in  a  different  col- 
umn. The  more  or  less  spoiled  ears  and  the  more  or 
less  spoiled  kidneys  of  twenty  other  children  who  re- 
covered never  are  recorded  on  the  books  at  all. 

Hence,  fourteen  cases  where  there  should  be  forty; 
and  two  deaths,  where  there  were  really  four,  are  re- 
corded officially  as  scarlet  fever. 


146  THE  NEW  PUBLIC  HEALTH 

This  instance  exemplifies  practically  the  whole  situa- 
tion; mild,  unrecognized,  and  concealed  cases;  cases  to 
which  physicians  are  not  called  at  all;  mistaken  diag- 
noses ;  a  superficial  report  covering  a  few  of  the  severer 
cases  only ;  death  reports  correct  so  far  as  they  go,  but 
not  showing  the  relation  of  the  death  to  the  preceding 
disease.  This  occurs,  not  occasionally,  in  a  few  com- 
munities, with  scarlet  fever  only,  but,  almost  every  time, 
in  almost  every  community,  with  almost  every  one  of 
the  infectious  diseases. 

The  returns  from  Anybodyville  are  small  in  number, 
it  is  true ;  but  multiply  these  by  all  the  similar  commu- 
nities which  make  similar  returns.  Anybodyville  re- 
ports two  deaths  and  fourteen  cases  from  scarlet  fever, 
where  there  were  four  deaths  and  forty  cases.  This  is 
"  only  "  two  deaths  and  twenty-six  cases  wrong.  But  if 
one  thousand  communities  report  similarly,  our  statis- 
tics are  wrong  two  thousand  deaths  and  twenty-six 
thousand  cases. 

Moreover,  see  how  the  percentages  are  twisted  and 
tangled.  Two  deaths  from  fourteen  cases  is  about  14 
per  cent.  Two  deaths  from  forty  cases  is  5  per  cent. 
Eour  deaths  from  fourteen  cases  is  28  per  cent.  Eour 
deaths  from  forty  cases  is  10  per  cent.  When  we  re- 
member that  the  number  of  cases  of  scarlet  fever,  and 
of  other  diseases,  is  often  calculated  from  the  deaths  by 
the  percentage  which  the  deaths  usually  are  of  the  cases, 
we  find  that  we  can  calculate  the  cases  from  one  hundred 
deaths  of  scarlet  fever  (on  the  above  returns)  as  seven 


COMMUNITY  DEFENSE  147 

hundred,  two  thousand,  three  hundred  and  fifty,  or  one 
thousand  —  how  very  valuable ! 

summaey 

The  vital  statistician  of  the  future  will  be  the  scien- 
tific manager  of  a  business  department,  for,  through  the 
epidemiologist  working  in  the  field,  he  will  know  where 
the  diseases  are,  not  where  they  were,  and  he  will  know 
which  disease  demands  the  most  attention.     He  will 
know  also  what  resources,  in  men  and  money,  the  health 
department  has,  with  which  to  fight  its  battles.     The 
correlation  of  these  two  factors  has  seldom  been  achieved, 
although  in  life  insurance  it  has  long  been  known  that 
their  inter-relations  were  the  absolute  sine  qua  non  of 
success.     Any  business  man's  first  step  in  reorganizing 
public  health  for  actual  service  would  necessarily  be 
(a)  to  determine  what  requires  to  be  done;  (b)  to  de- 
termine what  there  is  to  do  it  with.     The  maximum 
required  returns  from  the  minimum  necessary  expendi- 
ture should  be  the  only  motto.     To  secure  this  informa- 
tion, no  one  but  a  statistician  knowing  statistics,  but 
knowing  men  and  things  as  well  as  figures,  can  succeed. 
To  confine  his  work  to  deaths,   even  to  cases,   from 
preventable  diseases,  is  to  study  output  only,  with  no 
regard     to     income.     To     study     income,     as     is     so 
widely  done,  without  regard  to  whether  that  income  is 
spent   to   achieve   lessening  of   disease   and   death,    or 
merely  for  nuisances  or  smoke  inspection,   is  simple 
madness. 


CHAPTER  XIII 
ADMINISTRATION 

The  administrator  of  public  health  is  confronted  as 
we  all  are  in  every  line  of  life  by  the  necessity  for  dis- 
criminating ^Esthetics  or  what  we  would  like  to  have, 
Hygienics  or  what  we  need,  and  Economics  or  what  we 
can  actually  secure. 

Too  often  the  administrator,  tempted  by  the  desire  to 
please,  or  yielding  to  the  pressure  of  demands  made  by 
the  unknowing,  or  even  himself  suffering  from  confusion 
of  mind  as  to  the  relations  of  cause  and  effect  in  public 
health  work,  has  devoted  his  department  to  such  aesthet- 
ics as  might  be  within  his  grasp,  neglecting  entirely  or 
largely  the  truly  hygienic  measures  he  might  have  un- 
dertaken. Quite  generally,  out  of  date  laws,  ordi- 
nances devised  by  the  most  ignorant  of  lawmakers,  have 
compelled  the  most  wise  administrator  to  subordinate 
measures  he  knew  to  be  valuable  to  those  he  knew  to  be 
useless  for  the  suppression  of  disease  and  death.  Thus 
it  comes  about  that  many  health  departments  are  loaded 
down  with  expenditures  in  money,  men  and  time,  for 
non-health  purposes  which,  good  in  themselves,  or  at 
least  harmless,  absorb  the  forces  which  might  be  de- 
voted to  directly  improving  health  or  to  preventing  dis~ 

148 


ADMINISTRATION  149 

ease.  There  are  those  who  say,  "  If  the  object  is  a 
good  one,  why  object  to  the  Health  Department  doing 
it  ?  —  does  it  matter  to  the  citizen  whether  or  not  the 
garbage  is  removed  by  the  Health  Department  or  the 
Street  Department  so  long  as  it  is  removed  ?  "  This 
argument  would  be  passable,  if  all  health  departments 
had  unlimited  money  and  were  manned  by  experts  in 
every  line  of  municipal  care.  Then  there  would  be  no 
administrative  objection  to  handing  over,  not  garbage 
only  but  charities  and  corrections  and  the  customs  col- 
lection, inland  revenue  and  conduct  of  the  schools  to 
health  departments.  As  it  is,  however,  with  inade- 
quate means  for  even  their  proper  functions,  and  with 
experts  trained  in  medical  lines  or  cognate  subjects,  the 
health  department  supervising  utilities  of  this  kind  is 
a  splendid  example  of  carefully  constructing  a  razor, 
and  then  needlessly  using  it  as  an  axe. 

But  there  is  a  much  deeper  and  more  serious  error  in 
such  division  of  health  department  work,  the  great  error 
in  recent  public  health  administration,  the  error  of  edu- 
cating the  public,  not  by  words,  but  deeds,  to  the  con- 
ception that  aesthetics,  the  miscellaneous  methods  of 
municipal  housekeeping,  the  cleanliness  of  externals, 
the  neatness  and  promptness  of  the  garbage  and  ash 
collections,  are  the  essential  weapons  against  disease. 
As  well  say  that  the  ordinary  order  and  cleanliness  of 
the  wellkept  home  creates  it  a  fit  hospital  for  contagious 
diseases. 

Many  a  health  department  now  standing  high  in  the 


150  THE  NEW  PUBLIC  HEALTH 

estimation  of  the  citizens  and  gaining  praise  in  all  direc- 
tions from  those  who  see  its  spectacular  operations  for 
cleanliness,  smoke  prevention,  etc.,  is  really  not  only  a 
total  failure  in  suppressing  disease  (except  sometimes 
in  suppressing  the  fact  of  its  existence)  but  is  actually 
misleading  the  public  and  building  up  false  ideals  which 
ultimately  damage  the  community  and  the  race,  causing 
loss  of  life  and  money  immensely  in  excess  of  the  com- 
fort or  economy  secured  by  such  municipal  cleanliness. 
Municipal  cleanliness  is  excellent  in  itself  —  it  is  the 
substitution  of  municipal  cleanliness  for  the  real  dis- 
ease prevention  that  we  deplore. 

The  ideal  health  department  of  to-day  organized  to 
suppress  disease  and  death,  not  to  clean  streets  or  to 
fuss  about  the  plumbing,  need  at  the  present  time  con- 
sist of  but  five  or  six  technical  divisions  corresponding 
with  the  basic  essentials,  man  and  his  surroundings. 
These  are  the  Epidemiological  Division,  dealing  di- 
rectly with  the  individual,  sick  or  well;  primarily  for 
the  discovery  of  the  infected  persons,  secondarily  for  the 
control  and  elimination  of  the  sociological  conditions 
contributing  to  infection. 

Eor  the  surroundings  of  man  is  needed  a  Sanitary 
Engineering  Division  dealing  with  all  the  essentials  of 
construction  and  operation  of  public  or  private  utilities 
which  bear  upon  the  promotion  of  health  or  the  preven- 
tion of  disease  and  death,  i.e.,  for  the  control  of  the 
physical  sources  and  elimination  of  the  physical  routes, 
of  transfer  of  disease. 


ADMINISTRATION  151 

For  the  bookkeeping  of  this  combination  an  alert  ac- 
tive Vital  Statistics  Division  is  essential  —  not  for  the 
bookkeeping  of  dollars  and  cents  but  of  human  lives  and 
health. 

A  Laboratory  Division  is  required,  to  apply  to  the 
activities  of  the  epidemiologist  and  the  sanitary  en- 
gineer the  most  advanced  of  chemical  and  bacteriological 
work.  This  division  should  be,  like  the  others,  fully 
equipped  in  men  and  money  for  every  known  form  of 
investigation  into  the  preventable  diseases,  and  the  anal- 
ysis of  anything  which  may  be  useful  to  the  prevention 
of  disease,  especially  for  the  analysis  of  sewage,  water, 
milk  and  other  foods,  drugs,  poisons,  etc.,  in  brief,  for 
the  analysis  of  man  and  of  those  surroundings  of  man 
which  affect  him  disastrously,  or  favorably. 

A  figure  now  new  in  health  department  activities 
should  be  a  permanent  feature  in  the  future,  although 
at  the  present  time  the  work  he  could  do  would  be 
largely  investigative  and  advisory,  i.e.,  a  trained  Physi- 
ologist, devoting  himself  to  the  study  of  physiology  as  it 
relates  to  hygiene,  i.e.,  to  the  attainment  of  physical 
perfection  and  efficiency,  with  comfort;  and  the  main- 
taining of  the  same  through  a  long  life.  The  division 
which  he  heads  should  be  equipped  for  every  form  of 
investigation  into  food  values,  labor  conditions,  espe- 
cially in  factories  and  in  schools  (the  universal  fac- 
tories which  all  must  enter)  and  should  devote  itself 
wholly  to  studies  developing  ultimately  to  the  place 
where  actual  legal  enforcement  of  valuable  regulations 


152  THE  NEW  PUBLIC  HEALTH 

relating  to  hygienic  conditions  may  be  made,  not  lim- 
ited to  mere  physical  surroundings  but  also  including 
hours  of  labor,  housing  and  many  other  problems  now 
largely  drifting. 

In  those  communities  where  medical  school  inspec- 
tion is  under  boards  of  health  this  physiological  division 
might  well  directly  control  it.  When  under  well 
equipped  school  boards  the  actual  operations  of  the 
medical  inspection  may  well  be  conducted  in  close  co- 
operation with  this  division. 

Of  the  non-technical  divisions  a  most  important  one 
is  that  which  engages  itself  with  Publicity.  Although 
usually  best  managed  as  a  subdivision  of  the  adminis- 
trative mechanism,  this  division  should  be  regarded  as 
equally  important  with  any  other  and  should  be  in  the 
closest  touch  with  all  of  them,  keeping  records  of  and 
publishing  promptly  the  work  of  each  department  in  an 
acceptable  form ;  explaining  the  principles  and  aims  of 
the  whole  in  each  of  the  operations  it  undertakes ;  and 
posting  the  public  on  the  actual  conditions  found,  the 
problems  they  present,  the  remedies  proposed  and  the 
results  of  remedial  operations.  This  division  might 
well  use  lectures  and  similar  methods  as  well  as  news- 
papers and  its  great  keynote  should  be  —  must  be  — 
the  truth,  the  whole  truth,  and  nothing  but  the  truth. 

The  Administrative  Division  should  itself  be  the 
center  of  the  whole  mechanism,  seeing  with  the  eyes  and 
ears  of  all  the  other  divisions,  planning,  correlating, 
directing,  demanding  returns  for  all  monies  spent  and 


ADMINISTRATION"  153 

shifting  the  weight  of  a  large  General  Fund  from  divi- 
sion to  division  as  the  needs  vary.  The  finance  sub- 
division should  be  equipped  with  expert  accountants 
who  are  well  posted  on  the  needs  as  well  as  the 
mere  outgo  of  each  division.  Administration  is  a 
business  as  well  as  an  art  in  any  large  operation, 
whatever  its  purpose.  But  in  public  health  work  it  is 
a  business  and  an  art  which  is  supposed  to  be  and  there- 
fore should  be,  energized  and  directed  to  the  general 
physical  welfare  of  mankind;  enlightened  with  a  fine 
appreciation  of  relative  values ;  and  guided  by  the  great 
general's  discrimination  between  the  essential  and  the 
non-essential,  the  things  that  win  as  distinguished  from 
the  things  that  merely  seem  to ;  the  things  that  threaten 
in  appearance  only,  as  distinguished  from  the  appar- 
ently innocent  things  that  really  mean  great  mischief. 
The  head  of  the  administration  should  be  unham- 
pered by  any  Board  of  Strategy.  The  chiefs  of  his  own 
divisions,  picked  properly  to  begin  with,  should  form 
his  best  council,  and  he  should  seldom  need  other. 
Political  exigencies  should  control  him  no  more  than 
they  control  the  military  officer  in  the  face  of  the  enemy. 
The  Board  of  Health  of  to-day  is  often  a  mere  anachro- 
nism, built  up  when  there  were  no  experts,  with  the 
hope  that,  all  being  blind,  combining  one  with  another 
would  manufacture  sight  between  them.  Now  that 
men  really  versed  in  public  health  can  be  secured,  noth- 
ing is  gained  by  placing  a  merely  official  board  in  actual 
control,  for  if  composed,  as  many  boards  may  now  be,  of 


154  THE  NEW  PUBLIC  HEALTH 

experts,  they  tend  to  take  the  place  of  a  single  executive ; 
while  if  composed,  as  they  usually  are  in  practice,  of 
inexpert  laymen,  or  worse,  physicians  inexpert  in  public 
health,  but  who  are  nevertheless  under  the  supposed  halo 
of  a  medical  degree,  they  do  more  harm  than  good. 
A  very  level-headed  board  of  very  just,  far  seeing,  men 
will  sometimes  be  found  whose  advice  in  conference  is 
of  real  value  to  the  administrative  head  1  but  these  are 
the  exception,  and  many  Boards  are  merely  excuses  for 
political  control  and  diversion  to  spectacular  ends  of 
monies  which  should  be  expended  on  the  objects  for 
which  they  were  appropriated,  i.e.,  for  public  health 
and  the  diminution  of  disease  and  death.  Such  an 
ideal  Health  Department,  in  close  touch  with  every 
agency  dealing  with  social  or  physical  improvement, 
will  be  in  close  touch  with  the  medical  profession.  It 
should  not  be  burdened  with  general  hospital  manage- 
ment nor  as  a  rule  with  the  management  even  of  a  con- 
tagious disease  hospital :  but  it  should  control  the  situa- 
tion completely  so  far  as  such  agencies  have  to  do  with 
the  spread  or  prevention  of  spread  of  all  infections. 
In  the  hospitals  as  in  the  schools  and  factories  its  rule 
in  this  respect,  should  be  quite  absolute.  The  Admin- 
istrative Division  needs  a  law  subdivision  and  usually 
a  police  subdivision  also.  The  reporting  of  contagious 
diseases  by  physicians  should  be  enforced,  but  with  a 
properly  conducted  Epidemiological  division,  it  should 

i  It  has  been   the  writer's  good  fortune  to  work  under   such 
Boards  in  both  Minnesota  and  London. 


ADMINISTRATION"  155 

be  rather  the  rule  for  the  Health  Department  to  dis- 
cover and  report  cases  to  the  Medical  profession  for 
treatment  than  that  the  medical  profession  should  re- 
port infection  to  the  Health  Department.  Indeed  until 
the  existing  status  is  reversed,  until  Health  Depart- 
ments know  more  of  the  whereabouts  of  infectious  per- 
sons than  the  whole  medical  profession  can  tell  them, 
the  abolition  of  infections  will  remain  a  dream  of  the 
future. 

■We  have  spent  many  years  blaming  the  medical  pro- 
fession for  laxity  in  reporting,  without  stopping  to 
think  that  if  every  medical  man  reported  correctly  every 
infection  that  he  sees  however  trivial,  still  infection 
would  be  continued  through  those  cases  that  call  no 
physician,  and  through  infected  persons  who  are  not 
sick.  Until  Health  Departments  do  more  —  much 
more  —  than  perfunctorily  placard  only  reported  cases, 
there  is  no  inducement  to  physicians  to  report  their 
cases ;  and  until  Health  Departments  are  equipped  with 
means  and  insight  to  provide  properly  in  all  respects 
for  the  infected  persons  thus  cut  off  from  their  usual 
associations  and  operations,  such  segregation  is  an  in- 
justice that  the  public  will  continue  to  resent. 

So  long  as  governments  permit  infection  to  go  un- 
checked, relying  footlessly  on  physicians'  reports  alone, 
the  persons  who  unwittingly  become  infected  should 
have  rights  in  suits  of  damages  against  such  govern- 
ments. This  has  been  the  enlightened  ruling  with  re- 
gard to  typhoid  fever  contracted  from  a  public  water 


156  THE  NEW  PUBLIC  HEALTH 

supply.     There  is  no  reason  why  it  should  not  be  ex- 
tended to  every  form  of  infection  however  contracted. 

SUMMARY 

The  Health  Department  of  the  future  will  be  a  busi- 
ness department  for  the  suppression  of  disease  and 
death  and  the  promotion  of  general  high  health,  not  as 
at  present  a  pseudo-charitable  institution  for  the  con- 
duct of  a  jumble  of  activities,  a  muddle  of  municipal 
cleansing  and  sesthetics. 

The  administrative  head  will  be  an  expert,  not  a 
political  exigency;  and  his  lieutenants  will  be  men  of 
training  as  deep  and  broad  as  his  own,  each  in  their 
specialties.  These  will  be  epidemiology,  vital  statis- 
tics, sanitary  engineering,  bacteriology  and  chemistry: 
each  organized  on  the  broadest  basis  for  actual  efficient 
accomplishment  of  the  ends  of  public  health.  The  ad- 
ministrative division,  well  equipped  for  financial  super- 
vision and  executive  direction  of  the  whole,  will  never- 
theless be  devoted  to  the  one  end  of  accomplishing  re- 
sults; and  will  include  as  an  important  feature  a  pub- 
licity bureau  or  division ;  while  as  the  next  development 
of  the  future,  a  trained  physiologist  to  study  the  ques- 
tions of  hygienics  as  applied  to  the  community  may 
well  be  added. 

The  sanitary  inspections,  back  yard  cleanings,  street 
sweepings,  smoke  preventions,  weed  cuttings,  removal  of 
dead  animals,  garbage  disposals  and  other  like  physical 
functions  of  a  municipality  will  be  relegated  to  the 


ADMINISTRATION  157 

Public  Works  or  Street  Departments,  relieving  the 
Health  department  of  physical  burdens  and  setting 
them  free  for  their  true  sociological  work  with  human 
beings. 

This  scheme  is  not  by  any  means  for  big  cities  only. 
The  smaller  cities  and  towns  and  rural  districts  must  be 
combined  into  populations  of  20,000 ;  or  even  less  in 
sparsely  settled  areas.  For  each  of  these  a  similar  de- 
partment should  exist.  The  present  reproach  that  half 
the  population,  i.e.,  that  half  residing  in  the  country, 
is  practically  without  public  health  agencies,  must  be 
removed  and  every  citizen  treated  equally  wherever  he 
lives.  This  is  not  mere  abstract  justice  but  also  a  real 
need. 

The  realization  that  infection  moves  back  and  forth 
from  urban  to  rural  districts  and  vice  versa  should 
give  to  all  the  clearest  understanding  that  disease  in 
one  depends  upon  disease  existing  in  the  other  as  much 
as  in  itself  and  neither  city  nor  country  can  free  itself 
alone  but  both  must  act  together.  The  summer  col- 
onies of  city  people  in  the  country,  the  constant  visits 
of  country  people  to  the  cities,  the  growing  interchange 
in  every  way,  have  done  away  forever  with  distinctions 
from  the  public  health  standpoint.  No  government 
that  fails  to  recognize  this  can  succeed  in  public  health 
campaigns. 


CHAPTER  XIV 
COMMUNITY  DEFENSE  APPLIED 

TUBERCULOSIS    IN    GENERAL 

Previous  chapters  have  outlined  the  general  prin- 
ciples which  govern  modern  public  health  efforts.  The 
present  chapter  will  show  the  specific  applications  of 
these  principles  to  one  specific  infectious  disease, 
namely,  tuberculosis.  This  disease  is  selected  because 
the  same  principles  that  apply  to  all  other  infectious 
diseases  apply  to  it  and  because  it  is  the  most  important 
of  all  the  diseases  now  recognized  as  really  'preventable, 
with  the  exception  of  the  venereal  diseases. 

Tuberculosis,  in  all  forms,  is  due  to  the  growth,  some- 
where in  the  body,  of  a  certain  germ,  exactly  as  diph- 
theria and  typhoid  are  due  to  the  growth,  in  the  body, 
of  certain  germs.  There  are  many  very  definite  indi- 
vidual differences,  in  the  size,  shape,  manner  of  growth, 
etc.,  of  the  three  different  germs  of  these  three  different 
diseases,  and  these  differences  make  it  perfectly  possible 
to  distinguish  each  germ  from  the  others,  just  as  any 
farmer  can  distinguish  oats,  corn,  and  potatoes  from 
each  other. 

But  just  as  there  are  different  varieties  of  potatoes, 

158 


COMMUNITY  DEFENSE  APPLIED      159 

so  there  are  at  least  two  varieties  of  tuberculosis  germs 
which  affect  human  beings.  One  variety  is  what  is 
known  as  the  human  tuberculosis  germ  proper.  The 
other  is  found  chiefly  in  cattle  and  is  therefore  called 
the  cattle  tuberculosis  germ  (the  bovine  tuberculosis 
germ),  and  this  name  is  given  to  this  variety  even  when 
it  is  found  in  the  human,  as  it  sometimes  is. 

HUMAN    TUBERCULOSIS 

One  of  the  most  important  differences  that  the  germs 
of  human  tuberculosis,  of  diphtheria,  and  of  typhoid 
fever  show  amongst  themselves  is  not  a  difference  in 
size,  shape,  etc.,  but  in  the  parts  of  the  body  each  selects. 
Thus  the  diphtheria  germ  flourishes  chiefly  in  the  nose 
and  throat;  the  typhoid  germ  flourishes  chiefly  in  the 
intestine  and  perhaps  in  the  blood;  while  the  human 
tuberculosis  germ  will  flourish  almost  anywhere  in  the 
body,  glands,  bones,  joints,  intestine,  kidney,  brain, 
lungs.  This  selection  is  no  mere  accident,  although  we 
do  not  know  how  it  comes  about.  All  three  germs  enter 
the  body  chiefly  by  the  mouth,  conveyed  thereto  chiefly 
by  the  hands,  but  also  more  or  less  through  food  and 
milk,  and,  in  the  case  of  typhoid  fever,  through  water 
and  flies.  On  entering  the  mouth,  all  three  germs, 
which  are  of  course  far  too  small  to  taste  or  feel,  are 
swallowed  in  the  food,  milk,  etc.,  in  which  they  happen 
to  be  present,  or  merely  in  the  saliva,  if,  as  is  most  usual, 
they  reach  the  mouth  directly  or  indirectly  from  the 
fingers.     Once  swallowed,  all  three  pass  into  the  stom- 


160  THE  NEW  PUBLIC  HEALTH 

ach,  where  many  are  killed  by  the  acid  there  present, 
the  survivors,  if  any,  passing  on  into  the  intestine.  On 
this  journey  from  mouth  to  intestine,  some  are  left,  of 
course,  by  the  wayside,  stranded  on  the  tonsils,  throat, 
gullet,  etc.  Here  at  once  is  shown  their  respective 
peculiarities.  Of  all  the  diphtheria  germs  that  are  thus 
swallowed,  practically  only  those  that  are  stranded  in 
the  throat  will  nourish;  those  diphtheria  germs  which 
pass  on  into  the  stomach  or  intestine  are  destroyed  or 
pass  out  harmlessly.  On  the  other  hand,  typhoid  germs, 
if  stranded  on  the  throat,  do  not  nourish  there,  nor  do 
those  which  reach  the  stomach  flourish  in  that  organ. 
It  is  only  those  typhoid  germs  which  survive  the  jour- 
ney until  the  intestine  is  entered  that  can  succeed  in  pro- 
ducing typhoid  fever.  The  human  tuberculosis  germ 
has  a  still  longer  road  to  go.  Xot  only  must  it  pass 
mouth,  stomach,  and  intestine ;  also  it  must  be  absorbed 
from  the  intestine  into  the  blood,  as  the  food  is ;  but  it 
does  not  grow  in  the  blood.  The  blood  is  only  a  river, 
by  which  it  can  be  carried  to  a  favorable  developing 
ground.  We  do  not  know  at  all  why  human  tubercu- 
losis germs,  entering  the  blood  thus,  should  finally  settle 
and  grow  in  a  joint  in  one  person,  in  a  lung  in  another, 
in  a  kidney  or  a  gland  or  a  bone  in  another.  However, 
this  is  the  way  in  which  these  different  forms  of  human 
tuberculosis  develop.  The  old  idea  that  human  tuber- 
culosis of  the  lung  (consumption)  is  contracted  chiefly 
by  breathing  the  germs  directly  into  the  lungs  has  been 
definitely    upset.     The    lungs    are    infected    from    the 


COMMUNITY  DEFENSE  APPLIED      161 

blood-stream  chiefly,  just  as  are  the  other  internal  or- 
gans, bones,  and  joints. 

Another  and,  from  the  public  health  standpoint,  an 
even  more  important  difference  exists.  Diphtheria 
germs  developing  in  the  throat,  and  typhoid  fever  germs 
developing  in  the  intestine,  can  readily  escape  from  the 
body ;  in  the  case  of  diphtheria,  through  the  mouth  and 
nose  discharges;  in  the  case  of  typhoid  fever  through 
the  bowel,  and  sometimes  the  bladder,  discharges.  It 
is  the  escape  by  these  channels  of  these  germs  from  the 
body  which  makes  these  diseases  "  catching  "  or  "  infec- 
tious "  or  "  communicable,"  for  if  they  could  not  escape 
from  the  body  they  could  not  reach  other  persons  and 
therefore  could  not  be  "  catching."  But  in  human 
tuberculosis,  most  of  the  places  where  it  develops, — 
bones,  glands,  joints,  etc., —  are  not  connected  with  any 
opening  of  the  body  by  which  the  germs  may  leave  the 
body.  These  forms  of  tuberculosis  have  no  great  high- 
way to  the  outside  lying  at  their  doors  to  carry  the  germs 
out  to  other  persons.  Practically  only  in  human 
tuberculosis  of  the  lungs  is  such  a  highway  provided  for 
the  human  tuberculosis  germs,  although  sometimes  in 
bladder,  kidney,  and  intestinal  tuberculosis.  But  in  the 
latter  forms,  the  germs  do  not,  as  a  rule,  pass  out  by  the 
highways  provided  for  them  in  such  condition  or  such 
numbers  as  to  be  of  serious  importance  in  propagating 
the  disease.  In  human  lung  tuberculosis,  on  the  other 
hand,  the  windpipe,  throat,  and  mouth  form  a  highway, 
along  which  the  germs  may  escape  from  the  affected 


162  THE  NEW  PUBLIC  HEALTH 

lung  in  such  enormous  numbers  that  twenty-four  bil- 
lion per  day  have  been  detected  in  the  discharges 
(sputum)  from  the  lung  of  a  single  advanced  case,  al- 
though the  average  number  from  the  average  case  is 
usually  "  only  "  four  or  five  billion  daily. 

Thus  it  comes  about  that  human  tuberculosis  of  the 
lungs  is  the  only  common  form  of  human  tuberculosis 
which  is  much  to  be  feared  as  infectious.  Practically 
all  the  chief  forms  of  human  tuberculosis  are  derived 
from  the  sputum  of  cases  of  human  lung  tuberculosis, 
carried  chiefly  by  mouth-spray  and  on  the  hands,  and  if 
cases  of  human  lung  tuberculosis  did  not  act  to  spread 
infection  to  other  persons,  all  forms  of  human  tubercu- 
losis would  quickly  disappear. 

Moreover,  even  human  lung  tuberculosis  is  not  in- 
fectious in  the  early  stages,  i.e.,  when  the  germs  are 
growing  in  the  lung  tissue,  but  have  not  yet  reached  the 
air-passages;  because,  until  then,  the  germs  cannot  es- 
cape into  the  windpipe  and  so  by  the  throat  to  the 
mouth.  When  in  the  later  stages  the  germs  reach  the 
air-passages  the  way  for  the  escape  of  the  germs  to  the 
outside  and  so  to  other  mouths  is  "  open."  Persons  in 
this  stage  of  tuberculosis  are  called  "  open  "  cases,  and  it 
is  therefore  only  the  "  open  "  cases  that  are  seriously  to 
be  feared  as  infectious.  Because  of  this,  tuberculosis  is 
not  spread  much  in  the  public  schools.  Many  school 
children  are  tuberculous ;  but  open  cases  are  not  common. 
Sometimes  the  former  should  be  taken  out  of  school 
for  their  own  good,  but  the  latter  alone  are  dangerous. 


COMMUNITY  DEFENSE  APPLIED      163 

THE  ABOLITION  OF  CATTLE   TUBERCULOSIS   FROM  THE 
HUMAN" 

Although  the  cattle  tuberculosis  germ  differs  from 
the  human  tuberculosis  germ  somewhat  in  size,  shape, 
etc.,  the  most  important  public  health  difference  is  this : 
the  cattle  tuberculosis  germ  seldom  produces  lung  tuber- 
culosis in  the  human.  It  produces  bone,  gland,  joint, 
etc.,  tuberculosis,  but  lung  tuberculosis  hardly  ever. 
Consider  how  important  this  fact  is.  It  means  that 
cattle  tuberculosis  existing  in  a  human  can  very  seldom 
be  conveyed  from  that  human  to  another  human.  It 
other  words,  cattle  tuberculosis  may  be  transmitted 
from  cattle  to  man,  but  practically  is  not  further  trans- 
mitted from  man  to  man.  To  prevent  cattle  tubercu- 
losis in  the  human,  we  do  not  need  to  take  into  account 
existing  cases  of  cattle  tuberculosis  in  the  human,  but 
only  existing  cases  of  cattle  tuberculosis  in  cattle.  If 
we  free  our  cattle  of  cattle  tuberculosis,  we  shall  free 
our  humans  of  cattle  tuberculosis  also;  and  this  is  the 
only  practical  way  that  cattle  tuberculosis  in  the  human 
can  be  abolished  unless  and  until  the  human  race  aban- 
dons the  use  of  raw  cow's  milk. 

THE   ABOLITION"   OF   HUMAN"   TUBERCULOSIS 

How  can  we  abolish  human  tuberculosis?  Exactly 
as  we  can,  and  some  day  shall,  abolish  any  and  all  other 
infectious  diseases,  by  killing  off  the  germ  that  causes 


164  THE  NEW  PUBLIC  HEALTH 

it ;  exactly  as  we  have  almost  abolished  the  race  of  buf- 
falo by  killing  off  the  existing  buffalo.  We  know  well 
enough  that  when  the  last  buffalo  is  dead,  no  man,  how- 
ever wise,  no  government,  however  powerful,  could  ever 
produce  another  buffalo.  So,  once  the  existing  diph- 
theria or  scarlet  fever  or  tuberculosis  germs  are  all  dead, 
there  is  no  way  under  heaven  by  which  these  particular 
germs  could  be  produced  again.  Those  which  exist  now 
are  not  "  evolved  from  dirt  "  any  more  than  are  buffalo 
or  roses.  Those  which  are  living  to-day  are  simply  the 
descendants  of  those  which  existed  yesterday  and  so  on, 
just  as  in  the  case  of  buffalo  or  roses,  back  to  the  dawn 
of  history.  Once  any  race  of  plant  or  animal  is  wiped 
out,  it  can  never  be  redeveloped;  and  the  tuberculosis 
germ,  just  as  well  as  the  germs  of  diphtheria  or  typhoid 
fever,  can  be  abolished  exactly  as  the  megatherium  or 
dinosaur  has  been  abolished,  i.e.,  by  killing  off  the  exist- 
ing individuals. 

"  But  consider  the  enormous  numbers  and  the  tiny 
size  of  germs  and  that  they  are  present  everywhere, — 
in  air,  water,  food,  milk,  dust ;  in  and  on  everything  we 
touch  or  taste  or  handle.  It  is  quite  impossible  to  kill 
them  all." 

True,  germs  are  everywhere  but  not  disease  germs. 
We  know  some  fifteen  hundred  or  more  species  of  germs 
and  hardly  fifty  of  these  produce  disease,  while  only 
two,  already  mentioned,  produce  tuberculosis  in  the 
human.  That  these  germs  are  very  small  and  cannot 
be  slaughtered  individually  like  buffalo,  is  true,  but  it 


COMMUNITY  DEFENSE  APPLIED      165 

is  also  true  that  their  very  minuteness  means  that  bil- 
lions can  be  slaughtered  at  a  time,  if  they  are  only  kept 
together.  As  to  tuberculosis  germs  being  everywhere, 
all  over,  outdoors  and  indoors  —  this  is  not  true.  No 
more  important  fact  in  public  health  has  ever  been  for- 
mulated than  this,  due  to  that  keen  leader  in  public 
health,  Chapin  of  Providence:  The  germs  that  pro- 
duce disease  are  not  ubiquitous,  not  in  dust  everywhere, 
water  everywhere,  milk  everywhere.  They  are  chiefly, 
almost  wholly,  in  the  bodies  of  a  relatively  few  people, 
or  animals;  and  when  they  escape  from  those  bodies, 
where  alone  they  find  the  peculiar  food,  high  tempera- 
ture, abundant  moisture,  and  darkness  which  they  need, 
they  promptly  die  or  become  harmless.  Even  in  water, 
milk,  food,  etc.,  into  which  they  may  be  introduced 
from  infected  persons,  their  lives  are  short,  and  they 
must  quickly  reach  a  new  living  victim,  or  die. 

To  abolish  any  one  race  of  disease  germs  is  far 
easier  than  to  destroy  some  much  larger  things.  Thus 
to  abolish  flies  means  not  only  killing  all  flies,  indoors 
in  all  houses  everywhere,  in  all  stables  everywhere,  in 
and  around  all  dwellings  everywhere,  but  also  through- 
out all  fields  and  forests,  mountains  and  valleys  every- 
where, because  flies  are  hardy  outdoor  beings  as  well  as 
indoor  beings.  They  can  breed  and  flourish  almost 
anywhere,  where  any  kind  of  food,  even  in  vanishing 
quantity,  is  to  be  had.  Moreover,  they  can  move  of 
their  own  volition  with  promptness  and  despatch,  have 
quick  eyes  and  quicker  wings  to  escape  designing  ene- 


166  THE  NEW  PUBLIC  HEALTH 

mies,  and  in  a  thousand  ways  can  take  care  of  them- 
selves. 

Disease  germs,  in  contrast  with  the  fly,  are  very  tiny 
and  helpless  particles  of  protoplasm,  having  no  eyes  to 
see  an  enemy,  no  nose  to  smell  him,  no  means  of  run- 
ning away  from  him.  They  cannot  flourish  on  almost 
any  food,  but  need  the  living  tissues  of  the  human 
body ;  they  cannot  grow  at  almost  any  temperature,  but 
must  have  the  heat  of  the  human  body.  In  brief,  they 
are  not  merely  indoor  plants ;  they  are  incubator  plants 
and  cannot  grow,  thrive,  or  reproduce  themselves  in 
nature,  except  in  the  incubators,  which  our  bodies  (or, 
in  a  few  cases,  animal  bodies),  provide  for  them. 
Hence  if  we  were  able  to  take  a  visual  census  of  all  the 
living  tuberculosis  or  scarlet  fever  or  diphtheria  germs 
in  the  world  we  should  see  them,  not  in  the  dust  every- 
where, the  water  everywhere,  the  food  everywhere,  etc., 
but  in  a  very  few  places  only,  and  those  places  would 
be,  in  almost  all  cases,  the  bodies  of  humans  (or  ani- 
mals). 

Indeed,  we  can  foretell  just  about  what  the  census  of 
tuberculosis  germs  in  any  district  of  the  temperate  zone 
would  show.  It  would  show  about  one  person  in  every 
five  hundred  of  the  population  carrying  a  large  number 
of  active,  living,  growing  germs  in  the  lungs, —  germs 
that  were  escaping  to  the  outside  and  reaching  other 
persons'  mouths.  It  would  also  show  a  number  of  other 
persons  in  whom  the  germs  were  present  in  joints,  bones, 
glands,  etc.,  but  not  escaping  to  others;  and  it  would 


COMMUNITY  DEFENSE  APPLIED      167 

show  a  number  of  persons  affected  in  the  lungs,  and 
later  likely  to  develop  to  the  point  where  the  germs 
could  escape,  but  practically  harmless  to  others  so  far. 
Beyond  this,  hunt  high,  hunt  low,  search  garbage  bar- 
rels, manure  heaps,  dead  animals,  dusty  streets,  sewage, 
water,  foods,  milk,  etc.,  and  human  tuberculosis  germs, 
alive,  growing,  capable  of  producing  the  disease,  would 
seldom  be  found.  True,  in  the  immediate  neighborhood 
of  the  "  open  "  cases,  the  sputum  they  throw  out,  their 
mouth-spray,  and  their  hands,  would  show  the  germs; 
and  things  they  spit  into,  mouth-spray  into,  or  touch, 
would  show  for  a  short  time  a  few;  but  these  would  be 
dying  or  already  dead,  holding  out  danger  to  other  per- 
sons only  during  the  short  time  which  elapses  between 
leaving  their  happy  homes  in  the  human  lung  and  death 
outside  from  drying  and  starvation.  This  applies,  not 
to  tuberculosis  germs  alone,  but  practically  to  all  the 
germs  of  the  ordinary  infectious  diseases,  anthrax  and 
tetanus  forming  two  chief  exceptions,  both  compara- 
tively rare  diseases  in  civil  life. 

No  person  energetic  enough  to  advocate  the  abolition 
of  the  fly  should  hesitate  a  moment  to  advocate  the  far 
simpler,  smaller,  easier,  and  far  more  important  work 
of  abolishing  those  germs  that  alone  can  make  the  fly  a 
danger. 

In  brief,  the  method,  and,  I  believe,  the  only  rapid, 
complete,  effectual  method  of  abolishing  human  tuber- 
culosis, is  this :  find  the  "  open  "  cases  and  prevent  the 
spread  from  them  of  the  germs  they  alone  throw  out  in 


168  THE  NEW  PUBLIC  HEALTH 

numbers  and  condition  to  be  feared.  That  means,  find 
the  one  person  in  every  five  hundred  whose  infection 
threatens  all  the  rest,  and  supervise  him  just  enough  to 
keep  his  discharges  from  entering  other  people's  mouths. 

How  is  this  one  person  in  every  five  hundred  to  be 
found  ?  Not  without  hunting,  not  without  ingenious, 
skillful,  deliberate,  sagacious,  well-trained  hunters,  epi- 
demiologists as  devoted  and  persistent  in  their  work  as 
the  average  insurance  agent  is  in  his, —  men  who  devote 
themselves  to  the  abolition  of  tuberculosis  as  whole- 
heartedly as  any  merchant  does  to  making  money. 

And  how?  Where  shall  we  begin?  Must  we  can- 
vass the  whole  population  one  by  one?  True,  that 
would  do  it,  but  epidemiology  has  found  a  simpler, 
keener,  more  scientific,  far  more  economic  plan,  illus- 
trated for  typhoid  fever  in  a  previous  chapter.  Begin 
with  the  known  cases  and  search  the  zones  of  infection 
surrounding  each  for  mild,  unrecognized,  and  concealed 
cases.  (In  tuberculosis  the  search  for  carriers  is  prob- 
ably unnecessary,  certainly  at  the  present  time.) 

"  But  why  not  concentrate  on  the  incipient  lung  case, 
the  case  that  may  be  cured,  and  by  preventing  this  case 
from  going  on  to  the  t  open '  infectious  stage  get  rid  of 
danger  to  others  thus,  instead  of  by  attention  to  the 
open  case  ? " 

Eor  several  reasons  the  abolition  of  tuberculosis 
through  care  of  incipient  lung  cases  only  cannot  at  pres- 
ent be  accomplished. 

1st.  Because  incipient  cases,  in  the  truly  incipient 


COMMUNITY  DEFENSE  APPLIED      169 

"  non-open  "  stage,  are  discovered,  perhaps  are  discov- 
erable, in  a  very  small  percentage  only  of  their  total 
number. 

2nd.  Because  a  large  proportion  of  the  true  incipi- 
ents  so  found  would  not  go  on  in  any  case,  whether 
found  or  not,  to  the  open  stage ;  and  the  time  and  money 
and  efforts  spent  in  finding  and  supervising  them  would 
have  been  relatively  wasted. 

3rd.  Because  a  certain  proportion  of  the  incipients 
so  found  would  go  on,  in  any  case,  to  the  open  stage, 
and  thus  become  infectious  cases,  despite  all  efforts. 
In  these  alone  would  the  efforts  expended  be  of  service 
in  preventing  new  cases.  The  trouble  is  that,  in  the 
truly  incipient  stage,  it  could  not  be  determined  whether 
or  not  the  case  would  so  develop. 

4th.  Because  the  time  and  attention  devoted  to  in- 
cipients, in  the  effort  to  prevent  them  becoming  open 
cases,  would  imply,  as  it  has,  too  often,  so  far  implied, 
neglect  of  the  advanced  "  open  "  cases,  from  which  the 
danger  of  infection  is  so  immensely  greater. 

5th.  Because  if  all  the  truly  incipient  cases  were  dis- 
covered they  would  form  a  mass  of  persons  so  great 
as  to  be  beyond  handling  properly  by  any  at  present 
even  dreamed  of  force  of  attendants,  etc.  If,  as  at 
present,  only  a  very  small  proportion  were  found  the 
actual  situation  would  not  be  materially  changed. 

"  Would  you  then  cease  the  care  of  incipient  cases  in 
sanatoria,  and  concentrate  wholly  on  sanatoria  or  hos- 
pitals for  the  advanced  case  ?  " 


170  THE  NEW  PUBLIC  HEALTH 

No.  First,  because  the  tuberculosis  sanatoria  for 
incipients,  intended  though  they  are  for  incipient  cases, 
really  handle  very  many  "  open  "  cases,  and  to  that  ex- 
tent prevent  new  infections ;  secondly,  because  the  tuber- 
culosis sanatoria  for  incipients  do,  in  a  measure,  fulfill 
their  proper  function  of  cure  for  incipients  and  even 
early  "  open  "  cases  to  some  extent  and  hence  save  life. 
But  as  a  means  of  abolishing  tuberculosis,  the  ordinary 
tuberculosis  sanatorium  for  incipient  cases  is  quite  hope- 


The  thing  to  do  first  is,  find  the  recognized  "  open  '" 
cases,  whether  they  be  in  early,  advanced,  or  late  stages, 
and  place  them  where  they  can  spread  the  disease  no 
further.1  Then  search  the  "  zones  of  infection  "  sur- 
rounding them,  i.e.,  their  relatives  and  associates,  for 
mild,  unrecognized  or  concealed  cases,  and  also  for  in- 
cipients, handling  all  "  open "  infectious  cases  thus 
found  in  the  same  manner.  This  system  would  begin 
at  the  right  end  by  stopping  further  infection,  and 
would  incidentally  find  those  early  "  open  "  and  "  non- 
open  "  incipient  cases  wherein  sanatorium  treatment 
would  be  of  most  avail. 

SUMMARY 

Human  Tuberculosis  is  a  typical  infectious  disease, 
and  it  must  be  handled  on  the  same  principles  as  any 

i  The  County  Sanatoria  of  Minnesota,  Wisconsin  and  many 
other  States  furnish  exactly  this  place.  They  spell  the  abolition 
of  tuberculosis  if  properly  developed. 


COMMUNITY  DEFENSE  APPLIED      171 

other  infectious  disease;  hence,  by  blocking  the  routes 
of  infection,  but  chiefly  by  finding  the  sources  and  pre- 
venting spread  thence. 

Of  the  five  great  routes  of  infection, —  water,  food, 
flies,  milk,  and  contact, —  human  tuberculosis  travels 
chiefly  by  contact,  through  sputum,  mouth-spray,  and 
hands,  directly,  or  almost  directly,  from  patient  to 
prospective  patient.  Practically,  it  is  spread  exactly 
as  scarlet  fever  or  diphtheria  is  spread. 

Public  flies  and  public  food  supplies  are  compara- 
tively insignificant  conveyors  of  this  disease.  Public 
water  supplies  are  almost  negligible,  and  public  milk 
supplies  act  chiefly  in  conveying  cattle  tuberculosis 
to  man,  although,  if  the  milk  be  handled  by  tubercu- 
lous humans,  it  may  convey  human  tuberculosis 
also. 

It  is  evident,  then,  that  blocking  the  routes  of  human 
tuberculosis,  since  the  chief  one  is  contact,  really  in- 
volves the  far  more  important  measure  of  finding  the 
sources,  just  as  in  scarlet  fever,  or  diphtheria.  If  these 
sources  are  found  and  prevented  from  gaining  access  to 
the  routes,  the  routes  may  be  disregarded.  The  meas- 
ures for  finding  the  human  sources,  practically  the 
"  open  "  cases  of  lung  tuberculosis  in  the  human,  are 
epidemiological  and  have  already  been  discussed  in 
principle  before  (Chapter  V). 

The  transmission  of  cattle  tuberculosis  from  cattle  to 
human  contrasts  with  the  transmission  of  human  tuber- 
culosis from  human  to  human  in  that  it  occurs  almost 


172  THE  NEW  PUBLIC  HEALTH 

wholly  by  one  definite  route,  raw  milk;  scarcely,  if  at 
all,  through  contact. 

Since  this  one  route  can  be  absolutely,  easily, 
promptly,  and  inexpensively,  blocked  by  the  simple 
process  of  pasteurizing  or  otherwise  killing  the  germs 
in  the  milk,  there  is  no  reason  why  we  should  await  the 
equally  absolute,  but  more  difficult,  much  slower,  and 
very  much  more  expensive  abolition  of  the  sources,  i.e., 
the  elimination  of  tuberculous  cattle  from  all  herds, 
although  the  latter  should  be  gradually  pushed  to  com- 
pletion for  economic  reasons,  whether  the  use  of  raw 
milk  be  abandoned  or  not.  The  measures  necessary  for 
finding  the  animal  sources  (infected  milch  cows)  are 
the  well-known  tuberculin  test  of  herds,  with  proper 
repetitions,  and  the  elimination  of  the  tuberculous  ani- 
mals. 

Serious  enough  as  cattle  tuberculosis  in  the  human 
is,  its  prevalence,  nevertheless,  is  much  less  than  that 
of  human  tuberculosis,  its  infectiveness  from  human  to 
human  is  nearly  negligible  and  the  pasteurization  of 
milk  would  eliminate  it  from  the  human.  Hence,  if 
our  efforts  were  concentrated  wholly  on  abolishing 
human  tuberculosis  from  the  human,  more  cases  and 
more  deaths  would  be  prevented  in  one  year's  work, 
than  efforts  directed  to  abolishing  bovine  tuberculosis 
from  cattle,  however  successful,  could  possibly  achieve 
in  many  years. 


CHAPTEE  XV 

THE  CONTROL  OE  DIPHTHERIA,  SCARLET 
EEVER  &NT>  MEASLES 

Without  attempting  to  describe  the  technical  de- 
tails, a  sketch  of  the  modern  procedures,  such  as  should 
be  clear  to  all  laymen  dealing  with  the  schools,  is  worth 
while  as  an  illustration  of  the  advances  and  advantages 
of  the  new  practice. 

In  past  times,  and  of  course  even  now,  an  outbreak 
of  diphtheria  in  a  school  was  considered  the  signal  for 
"  immediate  action  " —  so  far,  so  good. 

But  that  action  often  consisted  chiefly  in  the  closing 
of  the  school  for  disinfection,  and  reopening  it  again 
as  soon  as  this  ceremony  of  purification  was  performed. 
Should  the  scare  be  great  enough  the  school,  perhaps, 
all  the  schools  of  the  community,  were  closed  for  weeks, 
to  prevent  spread  of  the  disease  amongst  the  children. 
The  length  of  the  period  of  closing  was  pure  guess  work. 
The  time  at  which  the  schools  were  reopened  seems  usu- 
ally to  have  been  decided  by  the  condition  of  "  scare  " 
in  the  community.  The  outbreak  sometimes  ended  in 
correlation  with  some  one  or  more  of  these  varieties  of 
action.     But  very  often,  the  outbreak  spread  while  the 

173 


174:  THE  NEW  PUBLIC  HEALTH 

schools  were  closed,  and  if  not,  took  a  new  lease  of 
life  when  they  were  reopened.  The  children,  ex- 
cluded from  nearly  all  schools,  were  not  effectively  for- 
bidden to  meet  at  play  or  work  outside  the  school. 

The  panic-origin  of  the  method,  its  lack  of  clean-cut 
object,  its  "  hit-or-missness,"  rendered  it  wholly  unsat- 
isfactory as  a  scientific  means  of  controlling  the  disease, 
to  say  nothing  of  the  upset  and  loss  of  school  time, 
the  disturbance  of  the  school  finances,  the  degeneration 
of  the  school  children  thus  forced  to  an  uncertain  vaca- 
tion, not  provided  for  at  home. 

The  new  method  never  interrupts  the  school  at  all. 
It  brings  to  bear  only  so  much  pressure  as  is  actually 
needed.  The  principle  is  simple  —  remove  the  infec- 
tion from  the  school.  The  practice  is  equally  simple 
—  discover  by  cultures  of  the  children's  throats  *  those 
who  may  be  infected ;  send  them  and  their  brothers  and 
sisters  home,  and  continue  all  the  school  operations  as 
before  with  the  remaining  children. 

The  infected  children  who  are  sent  home  must  be 
followed  to  their  homes  and  prevented  from  conveying 
their  germs  to  uninfected  companions  out  of  school. 
They  are  in  fact  isolated  until  such  time  as  (a)  the 
germs  they  carry  are  shown  by  proper  tests  to  be  non- 
virulent  or  (b)  the  germs  disappear,  of  themselves  (as 
very  often  happens)  or  under  treatment  (lemon- juice 
or  kaolin). 

i  Not  forgetting  the  throats  of  the  teachers  and  of  the  janitor, 
also.     Often  cultures  from  noses  also  are  advisable. 


DIPHTHEEIA  AND  SCAELET  FEVER     175 

In  institutions,  a  further  step  may  be  taken. 
Through  the  Schick  test,  the  children  who  are  immune 
to  diphtheria,  ranging  perhaps  an  average  of  50  to  60 
per  cent,  of  all  the  children,  may  be  kept  together  and 
all  infected  children  may  freely  associate  with  them, 
without  danger  of  disease.  The  non-immunes  are  like- 
wise kept  in  another  group,  and  watched  by  culture  and 
clinical  observation  for  the  development  of  further 
cases.     This  group  may  receive  antitoxin  also. 

The  advantages  of  this  simple  procedure  are  too  ob- 
vious for  need  of  expression  here. 

In  scarlet  fever,  a  very  similar  procedure  was  intro- 
duced and  developed  to  a  high  degree  of  perfection  by 
A.  J.  Chesley  in  Minnesota. 

The  principle  is  exactly  similar,  but  since  the,  as  yet, 
hypothetical  scarlet  fever  germ  cannot  of  course  be 
recognized  as  is  the  diphtheria  germ,  clinical  observa- 
tion necessarily  takes  the  place  of  cultures. 

As  in  diphtheria,  the  children  are  examined  at  the 
school;  but  by  direct  inspection  of  the  face,  tongue, 
throat,  glands,  chest,  sometimes  one  foot :  those  showing 
signs  of  recent  or  developing  scarlet  fever  are  sent  home, 
with  their  brothers  and  sisters,  and  the  remaining  chil- 
dren continue  at  school  safely. 

Because  scarlet  fever  may  be  incubating  in  children 
for  several  days  before  giving  outward  signs,  the  pro- 
cedure is  further  modified  from  that  used  in  diphtheria 
to  the  extent  that  the  inspection  just  described  is  re- 
peated every  day  for  a  week.     All  children  still  without 


176  THE  NEW  PUBLIC  HEALTH 

signs  of  scarlet  fever  may  then  continue  at  school  as 
safely  as  may  those  who,  in  a  diphtheria  epidemic,  have 
had  eliminated  from  amongst  them  the  diphtheria  in- 
fected throats. 

In  scarlet  fever,  exactly  as  in  diphtheria,  the  follow- 
ing up  to  their  homes  and  isolation  there  of  the  in- 
fected children  is  an  essential  to  prevent  spread  from 
them  amongst  school  children  after  school  hours,  or 
amongst  non-school  children  they  may  otherwise  en- 
counter. 

Quite  similar  methods  may  be  and  have  been  suc- 
cessfully applied  to  measles.  In  this  disease,  the  infec- 
tious period  begins  three  or  four  days  before  the  rash, 
with  the  beginning  of  the  earliest  symptoms,  which  usu- 
ally are  first  observed  as,  and  often  taken  to  be,  those  of 
a  heavy  cold,  with  reddened  eyes  and  hoarseness.  All 
schools  should  stand  ready  to  eliminate  from  amongst 
their  pupils  all  sick  children  —  for  the  sake  of  the  child 
itself,  but  even  more  for  the  sake  of  its  associates. 
Such  children  should  not  only  be  sent  home,  but  should 
not  be  returned  to  school  again  without  a  medical  in- 
spection, preferably  by  a  school  physician. 

SUMMARY 

Some  day  infection  will  be  so  well  controlled  outside 
the  schools  that  infected  children  will  not  enter  schools ; 
and  then,  school  outbreaks  will  be  unknown.  But  in 
the  transition  period  from  the  diluted  barbarism  of  to- 
day to  the  conditions  just  outlined,  diphtheria,  scarlet 


DIPHTHERIA  AND  SCAELET  FEVER     177 

fever  and  measles  can  be  detected  and  eliminated  from 
schools,  and  best  by  keeping  the  schools  open,  not  by 
closing  them,  provided  the  methods  outlined  above  are 
followed. 

Xot  only  do  these  methods  keep  the  schools  free  of 
infection  and  hence  make  them  "  the  safest  place  in 
town,"  but  also  the  follow-up  system,  also  outlined, 
provides  for  the  elimination  of  out-of-school  infection 
from  the  community. 

Of  course,  both  within  and  outside  the  schools,  the 
epidemiologist,  thoroughly  posted  on  the  natural  his- 
tory of  the  diseases  he  deals  with  and  keen  to  trace  its 
sources  and  its  routes,  is  a  sine  qua  non. 


CHAPTER  XVI 
VENEREAL  DISEASES 

We  know  how  to  prevent  any  infections  disease  the 
moment  we  know  where  its  sources  are,  if  we  can  con- 
trol them. 

In  tuberculosis  we  are  getting  control  slowly  of  the 
two  main  sources  and  routes,  tuberculous  cattle  and  the 
raw  milk  from  them  for  bovine  tuberculosis,  the  human 
consumptive  and  his  mouth  discharges  for  human  tuber- 
culosis. 

In  typhoid  fever,  scarlet  fever,  diphtheria,  etc.,  ex- 
actly the  same  things  are  true  and  exactly  the  same  sort 
of  principles  are  to  be  applied,  and  have  been  applied 
most  brilliantly  and  successfully. 

In  the  venereal  diseases,  however,  although  the  same 
principles  of  course  remain  as  true  as  ever,  their  appli- 
cation to  the  sociological  conditions  of  the  day  have  yet 
to  be  worked  out  upon  a  practical  footing. 

The  people,  as  a  whole,  have  overlooked  the  fact  that 
more  than  half  of  the  cases  are  innocently  contracted, 
and  attach  a  stigma  to  all  that  is  deserved  by  few. 
Hence  one  great  difficulty  in  the  discovery  of  cases,  and 
the  difficulty  in  dealing  with  them  after  their  discovery. 

178 


VENEREAL  DISEASES  179 

Moral  suasion  has  been  tried  for  thousands  of  years, 
and  venereal  diseases  have  increased  instead  of  dimin- 
ishing. 

The  elimination  of  these  diseases  from  the  race  is  the 
practical  duty  of  the  professional  public  health  man  and 
he  every  year  considers  it  more  seriously. 

Preliminary  steps  have  been  taken  to  determine  the 
extent  of  the  problem,  with  appalling  results,  but  these 
should  rather  urge  to  more  immediate  and  strenuous  ac- 
tion than  result  in  inertia  and  despair. 

It  has  been  pointed  out  elsewhere  that  education  of 
the  average  person  to  avoid  other  diseases  is,  while 
worth  while,  of  little  final  value,  because  infection  can- 
not be  recognized  by  laymen,  nor  can  the  channels  by 
which  it  travels  be  so  continuously  blocked  in  ordinary 
life  as  to  avoid  unrecognized  infection ;  hence  that  it  is 
the  duty  of  the  community  to  eliminate  infection  from 
itself  entirely  and  free  its  members  of  all  need  for  per- 
sonal defence.  This  is  everywhere  recognized  as  sound 
governmental  policy  in  relation  to  other  dangers,  fire, 
thieves,  invaders  —  why  not  in  relation  to  these  more 
constant,  more  inevitable  and  more  insidious  foes  ? 

The  sources  of  infection  are  the  venereally  infected 
persons  who  now  exist.  Unfortunately  these  are  not 
confined  to  any  group  or  class  or  profession,  but  are 
scattered  everywhere. 

The  routes  of  transmission  are  intimate  contact,  but 
not  necessarily  sexual,  or  when  sexual,  not  necessarily 
guilty ;  yet  of  a  nature  making  the  tracing  of  transmis- 


180  THE  KEW  PUBLIC  HEALTH 

sion  rather  a  delicate  task.  The  control  of  the  infected 
heretofore  has  not  been  recognized  as  anything  like  so 
important  as  the  control  of  scarlet  fever  or  diphtheria 
infection,  despite  the  far  greater  damage  that  they  do. 

While  prophylactic  disinfection  may  be  and  has  been 
practised  with  great  success  in  naval  and  military  cir- 
cles, the  apparent  endorsement  that  arrangements  to 
this  end  give  to  illicit  relations  makes  it  difficult  to  en- 
join or  even  urge  them  in  civil  life. 

Hence  the  venereal  problem,  while  gradually  taking 
shape,  is  as  yet  hardly  concrete  enough  to  permit  formu- 
lation of  a  definite  program. 

All  that  can  really  be  held  as  absolutely  demonstrated 
is  this:  however  the  solution  may  be  reached,  it  neces- 
sarily must  involve  one,  two  or  more  of  the  simple 
principles  established  for  the  control  of  other  infections : 
immunization,  avoidance  of  the  sources,  blocking  of  the 
routes,  elimination  of  the  sources;  the  latter  being  the 
highest  ideal.  The  first  is  as  yet  hypothetical;  the 
second  has  totally  failed  to  eliminate  these  diseases 
from  the  race,  although  a  perfect  method  when 
practicable  and  practised.  The  third  is  the  only  method 
successful  to  date  on  any  scale  large  enough  to  offer 
evidence  of  its  efficiency.     The  fourth  is  as  yet  a  dream. 

Education  of  children  in  sexual  hygiene  cannot  but 
be  of  benefit  in  some  cases  and  while  no  final  solution 
of  the  problem,  paves  the  way  to  it  by  doing  away  with 
the  false  modesty  that  envelopes  these  great  scourges 


VEKEKEAL  DISEASES  181 

of  the  race  in  a  sanctified  mystery  of  misery  that  con- 
duces greatly  to  their  successful  propagation. 

Wherever  "  hush  "  is  heard,  wherever  mystery  and 
mysticism  reign,  there  we  find  superstitious  practices 
and  suffering  beyond  belief. 

"  The  dark  places  of  the  earth  are  full  of  cruelty  " — 
and  doubtless  after  all  is  said  and  done,  publicity  will 
prove  if  not  the  solution,  the  first  step  to  the  solution, 
of  this  our  greatest  present  day  public  health  question. 


CHAPTER  XVII 

THE  CONCLUSION  OE  THE  WHOLE 
MATTER 

THE  DOING   OF   IT 

If  previous  chapters  have  succeeded  in  the  very 
earnest  attempt  they  made  to  show  what  the  new  public 
health  principles  are  and  how  they  have  become  estab- 
lished, the  one  momentous  matter  in  public  health  still 
left  unsolved  is  this  —  why,  why,  why  are  not  these 
principles  observed  ?  If  we  know  how  to  do  it,  why  is 
it  not  done  ? 

Chiefly,  because  the  general  public  does  not  know. 
They  still  believe  religiously  the  theories  that  were  be- 
ginning to  be  discarded  in  scientific  circles  twenty  years 
ago.  To  any  one  who  has  discussed  these  subjects  be- 
fore lay  audiences  it  becomes  most  evident  that  people 
the  most  refined  and  educated  still  believe,  concerning 
public  health,  almost  the  same  things  that  the  most  ig- 
norant hold. 

How  many  people  believe  that  gold  wedding  rings 
rubbed  on  the  eye  will  cure  styes  ?  That  green  apples 
cause  colic?  That  ear-rings  improve  sight?  That 
a  copper  wire  round  the  waist  prevents  rheumatism? 

182 


CONCLUSION  OF  WHOLE  MATTER     183 

That  horse-hairs  soaked  in  water  become  snakes  ?  That 
only  nasty  medicines  cure  ?  That  whiskey  is  good  for 
pretty  nearly  any  ailment  ?  That  the  moon  affects  luna- 
tics? That  tuberculosis  is  hereditary?  That  measles 
is  inevitable  ?  That  typhoid  comes  from  dead  weeds  in 
drinking  water?  That  red  flannel  (must  be  red!)  is 
good  for  sore  throats?  That  sewer  gas  is  poison? 
That  smallpox  can  be  telephoned  from  one  person  to 
another?  That  mosquitoes  come  from  decomposing 
leaves?  That  malaria  is  due  to  night-air?  That  ro- 
bust people  do  not  have  smallpox?  That  scarlet  fever 
scales  are  infectious  ?  That  raw  beef -steak  is  good  for 
a  black  eye  ?  That  drinking  cow's  blood  cures  consump- 
tion ?  That  the  smell  from  a  horse  stable  cures  consump- 
tion? That  if  medicine  is  good  for  sick  people,  it 
must  be  still  better  for  well  ones  ?  That  eating  turnips 
makes  one  brave  ?  That  onions  cure  or  prevent  small- 
pox ?  That  dead  bodies  necessarily  breed  a  pestilence  ? 
That  rusty  nails  produce  tetanus  (lock-jaw)  ?  That 
goats  in  a  stable  save  the  horses  from  glanders  ?  That 
in  epidemics  schools  should  be  closed?  That  Cuban 
Itch  is  not  smallpox?  That  washing  the  exterior  of 
the  body  removes  disease  from  the  interior  of  the  body  ? 
That  children  ought  to  have  "  children's  diseases "  ? 
That  the  younger  they  have  them  the  better  ?  That  all 
colds  are  due  to  cold  ?'  That  fever  is  due  to  heat  ?  That 
brain-fever  comes  from  excitement  or  strain  ?  That 
people  "  gradually  run  down,  and  it  turns  into  "  typhoid 
or    tuberculosis?     That    backache    indicates    kidney 


184  THE  NEW  PUBLIC  HEALTH 

trouble?  That  vaccination  is  worse  than  smallpox? 
That  you  "  mustn't  give  in  to  "  disease,  but  fight  it  off 
by  force  of  sticking  at  your  work  ?  That  cold  weather  is 
healthy  because  it  kills  germs  ?  That  oxygen  kills  dis- 
ease germs  ?  That  small  flies  grow  into  big  ones  ? 
That  cancers  have  roots  like  a  tree;  roots  which  can 
be  drawn  out  with  the  cancer,  if  care  is  exercised  ? 
That  grapeseeds  produce  appendicitis  ?  That  cherry- 
stones swallowed  may  grow  a  cherry  tree  in  your  stom- 
ach ?  That  pickles  sour  the  milk  of  a  nursing  mother  ? 
That  a  meat  diet  tends  to  produce  a  quarrelsome  dis- 
position ?  That  there  is  no  danger  of  infection  from  a 
sick  child  unless  a  doctor  has  pronounced  exactly  what 
the  particular  disease  is?  That  mild  attacks  of  infec- 
tious diseases  are  less  infectious  than  severe  ones  ? 

So  long  as  this  jumble  of  pure  myth,  current  tradi- 
tion, childhood  misunderstandings  carried  over  uncon- 
sciously into  the  serious  repertoire  of  adult  conceptions, 
control  and  form  the  basis  of  procedure  for  the  public 
health  thought  and  action  of  the  race,  so  long  will  pub- 
lic health  be  what  it  largely  is  to-day,  a  farce  and  laugh- 
ing stock. 

Until  these  absurdities  are  definitely  combated  and 
eliminated,  the  teaching  of  the  truth  is  retarded,  for  the 
public  tend,  not  to  replace  the  superstition  by  the  fact, 
but  to  adjust  one  to  the  other,  making  a  more  hideous 
jumble  than  ever.  Curiously  also,  it  is  the  fact  that  is 
modified  in  such  adjustment,  not  the  superstition.  We, 
as  a  race,  pride  ourselves  on  our  cold-blooded,  calculat- 


CONCLUSION  OF  WHOLE  MATTER     185 

ing  analysis  of  things,  our  elimination  of  old-world 
formulas,  of  old-world  rules.  Yet  in  public  health, 
nothing  is  too  ridiculous  or  far-fetched  to  find  ready 
believers  —  eager  strivers  after  mystery,  people  who 
prefer  complicated  non-sequitors  to  simple  facts. 

Four  of  the  most  common  fallacies  the  writer's  ex- 
perience of  public  discussion  has  elicited  are  illustrated 
here,  and  the  reader  may  easily  test  his  own  state  of 
knowledge  by  asking  himself  what  answers  he  would 
give  to  the  questions  here  presented : 

THE    CHIEF    OBJECTIONS 

1.  If  the  disease  germs  are  not  evolved  afresh  from 
dirt  or  decomposition,  but  are  descendants  of  their  fore- 
fathers, where  did  the  first  disease  germ  come  from  % 

We  do  not  know.  Where  did  the  first  wheat  come 
from  ?  Or  the  first  horse  ?  We  know  that  we  can  get 
no  wheat  now,  except  from  wheat,  nor  horses  except 
from  horses.  These  germs  are  plants  or  animals,  ex- 
actly as  wheat  or  horses  are.  That  they  are  tiny  no 
more  changes  this  law  of  descent  than  does  the  enormous 
size  of  a  whale  or  of  a  redwood  tree  make  them  excep- 
tions. "  All  life  from  life "  holds  true  in  nature 
through  the  whole  scale,  from  germ  to  human  beings. 
Besides,  under  the  microscope,  we  see  the  germs  "  de- 
scending "  from  their  forefathers. 

2.  If  dirt  does  not  breed  disease,  then  why  are  dirty 
people  so  subject  to  disease? 

Dirty  people  are  no  more  subject  to  disease  than 


186  THE  NEW  PUBLIC  HEALTH 

clean.  Infection,  if  it  reaches  either,  may  yield  dis- 
ease, in  either ;  if  it  reaches  neither,  neither  will  suffer. 
If  an  infectious  disease  enters  a  household,  the  dirtiest 
people  will  not  spread  it,  despite  their  dirty  habits,  if 
they  avoid  the  one  specific  "  dirt "  (the  discharges  of 
the  patient)  which  alone  is  harmful ;  the  cleanest  people 
will  not  fail  to  catch  it  if,  in  their  general  cleanliness, 
they  neglect  that  same  specific  "  dirt."  True,  dirt, 
carelessness  and  disorder  offer  some  indication  whether 
or  not  the  people  who  show  these  characteristics  would 
have  the  sense,  or  take  the  trouble,  to  avoid  the  one  dan- 
gerous "  dirt,"  should  it  appear.  On  the  other  hand, 
cleanliness,  thrift,  and  system  indicate  characters  likely 
to  handle  infectious  "  dirt "  with  the  same  care  they 
show  in  other  matters.  But  the  dirtiest  people  who 
make  the  proper  efforts  to  avoid  infection  can  and  do 
many  times  escape,  remaining  as  dirty  as  they  please  in 
other  ways.  The  cleanest  people  who  neglect  or  do  not 
know  the  methods  can  and  do  suffer. 

3.  If  you  tell  people  "  dirt "  does  not  breed  disease, 
you  are  praising  dirt  —  upsetting  all  the  careful  up- 
lift all  the  best  people  have  attempted  for  many,  many 
years. 

Suppose  a  wa£er-pipe  is  leaking  in  your  house,  flood- 
ing the  floors  and  damaging  everything.  Suppose  that 
when  the  plumber  is  hurried  to  the  rescue,  he  tests  the 
#as-pipes,  finds  a  leak,  stops  it,  and  tells  you  all  is  well. 
What  would  you  say?  True,  the  gas  leaked;  it  was 
right  to  stop  it;  but  the  water  goes  flowing  on!     Sup- 


CONCLUSION  OF  WHOLE  MATTER     187 

pose  to  your  objections  he  replies :  "  But  think  how 
bad  the  effect  would  be  on  our  campaign  against  gas- 
leaks,  if  we  failed  to  urge  that  gas-leaks  must  be 
stopped,  whether  that  stops  the  water-leaks  or  not.  If 
I  admit  that  gas-leaks  have  no  connection  with  water- 
leaks,  you  would  let  the  gas  flow  on.  I  must  make  you 
believe  the  water-leak  depends  on  the  gas-leak,  else  you 
won't  fix  the  gas-leak."  Stopping  gas-leaks  cannot  help 
water-leaks  nor  vice  versa.  Reducing  disease  will  not 
make  people  "  clean,"  nor  will  making  people  "  clean  " 
reduce  disease ;  only  the  one  "  cleanliness  "  of  avoiding 
infected  discharges  will  gain  this  end. 

4.  Why  do  you  talk  so  much  about  disease?  Teach 
healthy  living,  keep  the  body  strong,  well  clothed,  well 
fed,  and  you  need  not  fear  disease,  especially  infectious 
disease,  at  all. 

This  is  a  fallacy  so  widespread  that  even  physicians 
teach  it,  in  good  faith,  without  considering  that  they 
themselves  would  never  let  their  own  children,  be  they 
never  so  healthy,  run  with  a  measles  case,  or  mumps,  or 
scarlet  fever,  unless  their  children  had  had  the  disease 
before.  If  the  teaching  is  not  good  enough  for  prac- 
tical application  to  physician's  children,  it  is  not  good 
enough  for  public  health. 

You  see,  every  one  knows  that  children  who  have  had 
measles  very  seldom  take  it  a  second  time,  and  this  with- 
out regard  to  whether  they  are  robust  or  sickly,  healthy 
or  weak.  Every  one  knows,  too,  that  children,  healthy 
or  sickly,  who  have  not  yet  had  measles,  almost  invari- 


188  THE  NEW  PUBLIC  HEALTH 

ably  catch  it  if  they  are  exposed.  Practically,  the  same 
is  true  of  scarlet  fever,  mumps,  whooping  cough,  small- 
pox, chickenpox,  etc.  It  is  not  so  true  of  tuberculosis, 
diphtheria,  or  typhoid,  since  those  who  have  had  tuber- 
culosis, diphtheria,  or  typhoid  may  take  it  again;  al- 
though again  without  regard  to  whether  they  are  healthy 
or  sickly. 

In  measles  and  the  other  diseases  like  it,  persons  ex- 
posed who  do  not  contract  the  disease,  escape,  not  from 
good  health,  but  just  because  they  have  within  their 
bodies  a  certain  antidote  to  the  particular  poison  of  that 
particular  disease.  Any  one  can  prove  this  to  himself, 
if  he  will  think  a  moment.  If  general  good  health 
really  did  protect  against  these  diseases,  a  child  who 
could  not  catch  measles,  because  protected  by  his  gen- 
eral good  health,  could  not  catch  scarlet  fever,  either, 
for  the  same  general  health  would  save  him  from  them 
both.  But  every  one  knows  that  the  child  who  cannot 
catch  measles  (because  he  has  had  it)  must  nevertheless 
be  guarded  from  scarlet  fever,  unless  he  has  had  that 
too.  In  brief,  an  attack  of  these  diseases  gives,  in 
most  persons,  an  immunity;  that  is,  an  antidote  is 
formed,  which  then  protects  them  from  having  it  again. 
But  there  is  a  different  antidote  for  each  disease.  Hav- 
ing had  measles  once  is  excellent  protection  against 
measles,  but  it  is  no  protection  at  all  against  scarlet 
fever  or  mumps  or  any  other  illness. 

In  diphtheria  an  antidote  is  formed,  but  often  disap- 
pears again,  and  therefore  this  disease  may  be  suffered 


CONCLUSION  OF  WHOLE  MATTER      189 

more  than  once.  In  typhoid  also  an  antidote  is  formed 
lasting  a  year  or  two.  We  know  something,  and  are 
learning  more,  of  this  antidote  against  typhoid.  We  do 
not  know  yet  much  about  that  which  perhaps  protects 
against  tuberculosis. 

Xow,  no  one  dreams  that  the  antidote  for  measles  can 
be  developed  by  diet,  exercise,  or  clothing ;  by  fresh  air, 
drugs,  or  anything  in  fact,  except  by  suffering  an  at- 
tack from  the  measles  germ.  Nor  can  any  one  seriously 
believe  that  the  antidotes  for  typhoid  or  chickenpox, 
etc.  (except  that  for  smallpox  vaccination  takes  the 
place  of  an  attack  of  smallpox),  can  be  developed  except 
by  equivalent  means.  If  "  good  health  "  will  not  pro- 
tect against  any  of  these  diseases,  taken  one  by  one,  how 
can  "  good  health  "  protect  against  all  of  them  taken  to- 
gether ? 

So  we  might  deal  with  fallacy  after  fallacy,  all  based, 
however,  on  two. 

POPULAR    FALLACIES 

The  first  of  these  is  that  infectious  diseases  come 
from  "  general  bad  surroundings."  The  truth  is  that 
they  come  solely  from  certain  germs  growing  in  the 
body,  and  practically  the  only  sort  of  "  bad  surround- 
ings "  which  causes  infection  is  association  with  one  of 
these  infected  bodies  or  with  its  discharges. 

The  second  great  basic  fallacy  is  this,  that  "  general 
good  health  "  protects  against  infection.  The  truth  is, 
that  the  only  true  protections  against  germs  we  know 


190  THE  NEW  PUBLIC  HEALTH 

are,  first  and  best,  to  keep  them  out  of  the  body;  and, 
second,  to  have  within  the  body  the  special  antidote  for 
each  particular  germ.  We  vaccinate  against  smallpox, 
but  that  does  not  save  us  from  typhoid  fever.  We  vac- 
cinate against  typhoid  fever,  but  that  does  not  save  us 
from  smallpox.  If  we  could  vaccinate  against  every 
disease  (as  perhaps  some  day  we  shall  be  able  to  do) 
we  would  be  safe,  despite  the  germs,  at  least  while  the 
protection  lasted,  and  after  that  we  could  vaccinate 
again. 

But  how  much  better  to  abolish  the  germs,  which 
means  guarding  all  persons  in  whom  they  are ;  and  then 
we  would  never  need  any  sort  of  vaccination ! 

Surely,  the  thing  to  do  for  one's  own  sake,  and  still 
more  for  the  sake  of  our  associates,  is  to  find  the  in- 
fected persons,  or  animals,  that  alone  can  cause  disease 
in  the  true  sense,  and  keep  them  so  protected  while  the 
danger  lasts  that  they  will  do  no  harm.  Then,  when 
their  stock  of  germs  is  dead  and  done  with,  remove  all 
the  restrictions. 

NEW   FASHIONED    QUARANTINE 

You  will  say  that  that  is  only  old-fashioned  quaran- 
tine. It  is,  in  principle,  but  modern  practice  changes 
it  so  completely  that,  practically  speaking,  new-fash- 
ioned quarantine  differs  from  old  as  much  as  motor  cars 
differ  from  camels,  although  both  are  means  of  locomo- 
tion. In  the  first  place,  old-fashioned  quarantine  did 
not  pick  out  all  dangerous  persons,  but  took  the  sick  who 


CONCLUSION  OF  WHOLE  MATTER     191 

form  but  part  of  the  infected,  and  also  took  the  well  who 
were  found  with  the  sick,  including  thus  some  who  were 
not  infected,  and  kept  all  these  practically  in  prison,  in 
their  homes,  or  ships,  or  wherever  else  they  were  stay- 
ing. Thus,  not  alone  were  many  infected  persons  over- 
looked and  many  uninfected  persons  wrongly  held,  but 
also  the  disease  spread  oftentimes  from  those  infected 
who  were  in  the  net  to  the  uninfected  who  were  kept  in 
with  them,  so  that  old-fashioned  quarantine,  while  it 
protected  the  community  but  partially,  meant  often 
poverty,  disease,  and  death  to  those  caught  in  its  toils. 
No  wonder  the  very  name  of  quarantine  makes  many 
people  shudder. 

New-fashioned  quarantine  is  not  a  blanket  method, 
blunderingly  catching  in  its  blindfold  grip  both  sick  and 
well,  the  harmless  and  the  harmful,  indiscriminately. 
New-fashioned  quarantine  requires  definite  detailed 
knowledge  applied  with  care  and  patience,  not  mere 
force. 

Now,  every  one  wishes  infectious  persons  handled  so 
that  infection  ceases.  The  infectious  persons  them- 
selves do  not  wish  to  spread  their  own  infection.  The 
thing  that  chafes  and  riles  the  average  person  is  not  re- 
striction but  unjust  restriction;  either  restriction  of 
non-dangerous  persons,  or  restriction  of  some  of  the 
dangerous  only,  while  others  just  as  dangerous  go 
free. 

No  mother  minds  the  exclusion  of  her  infectious  child 
from  public  school,  if  her  neighbor's  infectious  child  is 


192  THE  NEW  PUBLIC  HEALTH 

excluded  also.  Every  physician  would  report  his  cases 
if  every  other  physician  did  so  too. 

Here  then  is  the  solution,  based  on  human  nature,  on 
common  sense,  and  on  the  most  scientific  knowledge. 
Eind,  through  the  methods  of  epidemiology,  of  the 
laboratory,  and  of  the  vital  statistician,  skilfully  com- 
bined by  experts,  these  dangerous  persons,  whether  sick 
or  well  —  these  only  dangerous  persons,  those  who 
carry  on  them  or  in  them,  germs  of  infectious  diseases. 
Set  all  others  free,  but  keep  these  persons,  not  in  old- 
fashioned  quarantine,  but  under  such  control  that  their 
discharges  will  not  pass  to  others;  and  do  not  measure 
the  length  of  that  control  by  fixed  time  limits,  blind  and 
unjust  as  quarantine  itself,  but  measure  it  wholly  by  the 
length  of  time  the  germs  remain  in  or  on  the  body. 
The  moment  that  the  germs  have  left  those  persons  they 
are  no  longer  harmful  and  they  should  be  freed. 

To  do  this  properly  means  intimate  attention  and 
supervision  of  infectious  persons  by  men  who  know 
their  business  and  do  nothing  else.  If  one  such  man 
to  every  20,000  persons  began,  to-morrow,  everywhere, 
his  work,  infectious  diseases  in  ten  years  would  have 
vanished  and  would  have  become  mere  history. 

SUMMAEY 

This,  then,  is  the  conclusion.  The  old  ideas  have 
passed;  the  new  are  no  longer  theories  but  facts;  the 
methods  they  require  are  not  untried;  they  have  been 
practiced  for  years  in  many  places.     The  details  are 


CONCLUSION  OF  WHOLE  MATTER     193 

worked  out,  the  field  is  ready,  the  scope  and  cost  are 
known.  All  that  remains  is  to  apply  the  methods  al- 
ready developed  to  all  infections,  thus  wiping  them 
all  out,  once  and  for  all.  The  way  is  clear,  what  re- 
mains is  to  follow  it ;  the  method  is  known,  what  remains 
is  to  carry  it  out ;  the  thing  we,  as  a  race,  for  centuries 
have  prayed  for,  can  be  done ;  all  that  remains  is  to  do 
it. 

Each  generation  of  Americans  pays  now  for  infec- 
tious disease  ten  billion  dollars  at  the  least,  and  has  the 
diseases,  too  I  Why  not  pay  one-tenth  this  sum  and  rid 
ourselves  of  all  of  them  forever  ? 


APPENDIX 


APPENDIX 
SYLLABUS  OF  PUBLIC  HEALTH  TEACHING 

As  an  example  of  the  sort  of  material  which  should 
be  presented  to  school  children,  the  following  syllabus 
already  in  use  in  Minnesota  is  appended.  This  was 
prepared  by  the  writer  in  co-operation  with  Mr.  C.  G. 
Schulz,  State  Superintendent  of  Education.  It  was 
intended  to  supply  to  the  public  school  teachers  of  the 
State  a  condensed  but  accurate  outline  which  they 
should  then  put  into  their  own  words  for  the  informa- 
tion of  their  pupils.  Syllabus  No.  1  might  well  be 
taught  in  all  grades;  syllabus  No.  2,  in  whole  or  in 
part,  in  all  grades;  syllabus  No.  3,  in  the  sixth  and 
higher  grades ;  while  syllabus  No.  4  is  applicable  rather 
to  the  eighth  and  higher  grades,  thus  including  the  high 
and  normal  schools. 

Elementary  and  simple  as  the  information  given 
may  appear  to  those  who  are  conversant  with  all 
phases  of  Public  Health,  the  writer's  experience  is  that 
the  most  enlightened  and  well-educated  of  those  of  the 
laity  who  received  their  education  in  times  past,  when 
nothing  of  this  nature  was  offered,  find  in  these  leaf- 
lets a  very  great  deal  of  information  which  is  to  them 
new,  intensely  interesting,  and  often  quite  revolution- 

197 


198  APPENDIX 

ary.  These  leaflets  have  been  prepared  with  the  utmost 
care  and  submitted  to  a  number  of  the  highest  author- 
ities in  each  subject  treated  of,  in  order  to  assure  the 
strict  accuracy  and  up-to-dateness  of  the  statements 
made. 

Prepared  by  H.  W.  HILL,  M.B.,  M.D.,  D.P.H. 
No.  1.    GEKMS  AND  DISEASE 

1.  Not  less  than  1500  kinds  of  germs  exist  —  but  only 
about  50  to  75  produce  disease.     Remember  these  two  classes : 

(a)  disease  germs  and  (b)  all  other  kinds. 

2.  Germs  of  all  kinds  are  simply  tiny  plants  (or  animals)  ; 
some  spherical,  some  more  or  less  sausage  shaped;  so  small 
that  from  100,000,000  to  200,000,000  might  lie  side  by  side 
on  a  thumbnail,  yet  could  not  be  seen. 

3.  Germs  of  any  kind  never  "  evolve "  from  dirt.  They, 
like  other  plants  (or  animals),  come  only  from  predecessors. 
They  increase  in  number  by  single  germs  separating  into 
two;  then  each  of  these  grows  and  likewise  separates;  this  is 
repeated  about  every  twenty  minutes,  when  conditions  are 
good  for  the  germs,  giving  about  1,000,000,000  descendants  in 
ten  hours. 

4.  Conditions  good  for  the  germs  mean:  (a)  much  water, 

(b)  the  right  food,  (c)  the  right  temperature,  (d)  darkness, 
(e)  the  right  atmosphere.  These  differ  for  different  kinds 
of  germs;  most  disease  germs  find  the  living  body  the  best 
place  for  them :  when  they  leave  it,  sunlight  and  drying  soon 
kill  or  disable  them. 

5.  Many  different  kinds  of  germs  that  do  not  produce  dis- 
ease flourish  on  or  in  our  skins,  noses,  mouths  and  intestines 
all  the  time. 

6.  We  all  pass  our  germs  on  to  other  people  whom  we  meet, 


APPENDIX  199 

and  they  pass  theirs  on  to  us.  But  this  does  no  harm,  unless 
disease  germs  are  present  too.  Disease  germs  are  found 
chiefly  in  persons  who  have  or  have  had  some  infectious 
disease. 

7.  Neither  disease  germs  nor  other  kinds  can  jump  or  fly 
from  one  person  to  another;  they  are  carried,  chiefly  in  the 
discharges  from  the  nose,  mouth,  bladder  and  bowel. 

8.  These  discharges  are  exchanged  chiefly  by  mouthspray, 
sputum,  and  hands;  also  by  things  touched  by  mouthspray, 
sputum  or  hands. 

9.  Mouthspray  means  the  small,  sometimes  invisible,  drops 
of  liquid  from  the  mouth  that  we  throw  out  when  we  sneeze 
or  cough  or  talk  or  sing  or  shout;  in  quiet  breathing  they 
are  not  thrown  out. 

10.  Sputum  is  spit  —  the  liquid  from  the  mouth,  gener- 
ally mixed  with  liquid  from  the  nose  or  lungs.  When  it  is 
thrown  out  where  it  can  be  stepped  on  it  may  be  carried  to 
other  people,  chiefly  on  feet  of  animals  or  shoes  of  humans. 

11.  Hands,  most  of  all,  carry  all  kinds  of  germs  from  one 
person  to  another  because  hands  carry  mouthspray,  sputum, 
nose,  bladder  and  bowel  discharges  to  other  people's  hands, 
and  to  things  that  other  people  touch. 

12.  Although  most  healthy  people's  germs  are  not  disease 
germs  and  are  therefore  harmless  to  other  people,  it  is  hard 
to  tell  when  even  healthy  people  may  get  disease  germs  from 
some  one  else  —  therefore 

13.  Try  to  keep  your  hands  out  of  your  mouth  and  nose, 
and  away  from  other  discharges,  unless  they  are  washed  well 
before  (for  your  sake)  and  then  washed  well  afterwards  (for 
others'  sake). 

14.  Try  not  to  handle  any  food,  cups,  spoons,  or  other 
things  which  other  people  may  put  into  their  mouths,  unless 
your  hands  are  first  washed  clean  from  your  own  nose,  mouth, 
bowel  and  bladder  discharges. 


200  APPENDIX 

15.  Try  not  to  leave  any  fresh  moist  discharges  from  your 
body  where  other  people  or  animals  will  touch  them,  or  step 
on  them;  or  where  flies  will  get  at  them  and  carry  them  to 
other  people's  food. 

16.  Water  and  milk,  as  well  as  food  and  flies,  carry  dis- 
charges to  other  people.  Therefore  don't  let  your  discharges 
get  into  or  on  any  of  them. 

17.  Try  to  get  other  people  to  be  as  careful  as  you  are. 

18.  Try  not  to  let  other  people  pass  on  their  germs  to  you, 

ESPECIALLY  IF  THEY  HAVE  ANY  KIND  OF  DISEASE  GERMS  (tuberCU- 

losis,  typhoid,  scarlet  fever,  measles,  etc.). 

No.  2.    FOOD  AND  WATER 

1.  Food  and  water,  next  to  ourselves,  are  the  most  im- 
portant physical  things,  for  they  are  what  we  are  made  of; 
we  are  about  70  per  cent,  water,  the  rest  food. 

2.  When  first  born,  we  weigh  about  7  to  8  lbs.,  as  adults 
120  to  200  lbs.  The  difference  comes  from  part  of  the  food 
and  water  we  have  taken  in. 

3.  A  large  part  of  the  food  we  eat  does  not  become  part  of 
us,  but  is  burned  up  as  fuel  to  keep  our  bodies  going.  Chil- 
dren usually  gain  weight  fast;  because  they  eat  more  than 
they  burn  up.  Adults  usually  do  not  gain  weight  much; 
because  they  burn  up  about  as  much  as  they  eat. 

4.  Our  food  comes,  directly  or  indirectly,  from  the  soil  — 
the  crust  of  the  earth.  Therefore  we  are  made  of  the  crust 
of  the  earth.     So  are  all  plants  and  animals. 

5.  The  crust  of  the  earth  is  made  up  of  about  80  elements 
—  about  one-fourth  of  these  go  to  form  our  bodies.  These 
include  carbon  (found  in  diamonds  and  coal),  oxygen,  hy- 
drogen (found  in  air  and  water),  nitrogen  (found  in  air), 
phosphorus,  sulphur,  sodium,  potassium,  calcium,  magnesium, 
iron,  chlorine,  iodine,  fluorine,  etc.  (found  in  various  salts 
in  food  and  water). 


APPENDIX  201 

6.  We  cannot  feed  ourselves  on  these  elements;  they  must 
be  combined  from  the  soil,  air,  and  water  by  bacteria  and 
plants  into  forms  we  can  use;  often  we  get  the  combinations 
we  need  by  eating  animals,  which  themselves  live  on  plants. 

7.  The  chief  combinations  we  can  use  are  known  as  fats, 
carbohydrates,  proteins,  vitamins,  salts,  water. 

8.  Fats  (including  oils)  are  found  in  fat  of  animals  (lard, 
suet,  etc.) ;  and  oil  of  plants  (olive  oil,  peanut  butter,  etc.). 
They  consist  of  carbon,  oxygen  and  hydrogen. 

9.  Carbohydrates  are  combinations  of  carbon,  oxygen  and 
hydrogen  also,  but  differ  from  fats  in  the  way  they  are  put 
together.     They  include  starches  and  sugars. 

10.  Proteins  form  the  main  substance  of  white  of  egg,  lean 
meat,  lean  fish;  and  are  found  also  in  plants.  Proteins  are 
combinations  of  carbon,  oxygen,  hydrogen,  and  nitrogen, 
with  phosphorus,  sulphur,  and  other  elements  present  in 
various  amounts. 

11.  Vitamins  are  peculiar  things,  essential  to  nutrition; 
they  are  present  in  raw  plants,  fresh  milk,  etc. 

12.  Salts  are  combinations  of  calcium,  magnesium,  etc., 
with  oxygen,  hydrogen,  etc.:  they  are  useful  in  many  ways 
in  the  body;  calcium  especially  in  forming  bone. 

13.  Water  is  the  great  solvent  and  carrier  of  material  from 
place  to  place  in  the  body:  blood  is  nearly  all  water,  and 
carries  food  and  oxygen  to  the  muscles,  brain,  etc.,  and 
waste  matter  from  them  to  the  kidneys  and  lungs. 

14.  Since  the  really  living  parts  of  us  are  largely  protein, 
only  protein  can  be  used  to  repair  waste  or  add  to  our  bodies. 
We  cannot  long  survive  on  a  diet  without  protein  in  it. 

15.  But  part  of  the  protein  we  eat  and  all  of  the  fat,  oil, 
starch  and  sugar  is  useful  only  as  fuel. 

16.  All  of  this  fuel  is  burned  in  the  body,  in  the  muscles, 
brain,  etc.  Our  lungs  make  the  draft  for  the  fire,  and  let 
out  the  "  smoke,"  carbonic  acid.     (See  "  Air,"  par.  4  and  5.) 


202  APPENDIX 

17.  Fats  and  carbohydrates,  if  not  burned  up  at  once,  are 
stored  as  fat;  some  carbohydrate  is  stored  as  animal  starch 
(glycogen)  in  liver  and  muscle.  Sugar  and  starch  in  excess 
make  people  stout. 

18.  Fat  in  the  body  is  stored  fuel,  ready  for  use  on  occa- 
sion. Very  thin  people  have  no  reserve  fuel,  very  fat  people 
have  too  much. 

19.  Children  under  one  year  should  have  water  and  human 
milk  —  nothing  else,  if  possible. 

20.  Children  over  one  year  should  be  carefully  taught  to 
use  all  good  "  adult "  foods ;  fats,  carbohydrates,  proteins, 
vitamins,  salts,  water. 

21.  All  growing  children  need  protein,  to  add  to  their 
bodies  as  well  as  to  repair  waste.  Sugar,  starch,  and  fats, 
are  good  fuels  for  children. 

22.  Healthy  adults  need  protein  for  repair  of  waste  only. 

23.  Boys  from  9-13  need  as  much  protein  as  a  man.  Boys 
from  14r-19  need  more. 

24.  Girls  of  11  need  as  much  as  women  of  30.  Children 
need  proteins  in  summer,  although  they  are  said  to  be  "  heat- 
ing." Cool  the  children  by  proper  radiation,  not  by  protein 
starvation.     (See  "Air,"  par.  3.) 

25.  To  be  sure  of  vitamins,  use  some  fresh  raw  food  (fruit, 
etc.)  every  day. 

No.  3.    AIR 

1.  The  important  points  about  ordinary  air  relate  to  its 
oxygen,  nitrogen,  carbonic  acid,  water  vapor,  temperature, 
circulation.  We  use  air  for  (a)  cooling,  (b)  breathing. 
Normal  air  consists  of  about  one-fifth  oxygen,  four-fifths 
nitrogen  and  four  parts  in  10,000  carbonic  acid.  The  water 
vapor  varies  very  much. 

2.  We  are  like  internal  combustion  engines  (see  "Food," 


APPEXDIX  203 

par.  16)  in  that  we  need  cooling;  like  an  automobile  engine, 
we  are  cooled  by  air  and  water. 

3.  The  skin  is  our  great  radiator;  the  air  itself  cools  our 
skins  directly ;  and  also  by  evaporating  the  water  (sweat) 
that  we  constantly  pour  out  on  our  skins. 

4.  We  are  like  engines  also  in  that  we  use  air  to  help  burn 
our  fuel  (see  "  Food,"  par.  16).  We  draw  the  oxygen  through 
our  lungs  to  the  blood,  which  carries  the  oxygen  to  all  parts 
of  the  body,  and  brings  back  the  carbonic  acid. 

5.  The  "  smoke  "  we  make  is  invisible ;  it  is  the  carbonic 
acid  we  throw  out  from  our  lungs. 

6.  The  old  idea  of  "good  ventilation"  largely  neglected 
water  vapor,  temperature  and  circulation,  and  concerned 
itself  chiefly  with  oxygen,  nitrogen  and  carbonic  acid:  it 
recognized  breathing  but  overlooked  cooling. 

7.  The  new  discoveries  (Fliigge,  Leonard  Hill,  etc.,  during 
the  last  8  or  10  years)  show  that  air  seldom  can  be  too  bad 
to  breathe:  it  is  very  often  too  bad  for  successful  cool- 
ing. 

8.  This  means  that  ordinary  "bad  air"  is  not  bad  on 
account  of  its  effects  on  the  lungs,  but  on  account  of  its 
effects  on  the  skin. 

9.  Thus,  experimentally,  men  in  "foul"  air,  suffering 
headache,  drowsiness,  etc.  (the  result  of  bad  ventilation  in 
an  airtight  room),  were  allowed  to  breathe  good  air  through 
tubes  leading  to  the  outside  of  the  room.  They  were  not 
helped  by  it.  Men,  outside  the  room,  in  good  air,  were  forced 
to  breathe  the  foul  air  through  tubes.  They  were  not  hurt 
by  it. 

10.  True  it  is  theoretically  possible,  in  a  really  airtight 
room,  to  use  up  the  oxygen  in  breathing  and  fill  the  room 
with  carbonic  acid  thrown  out  from  the  lungs. 

11.  But  our  houses  and  rooms  are  not  airtight:  oxygen 


204  APPENDIX 

will  pass  in  through  the  walls  themselves,  if  no  windows  or 
doors  are  open :  carbonic  acid  will  pass  out  through  the  walls. 
This  is  especially  true  in  winter,  when  the  temperatures 
inside  and  out  differ  much. 

12.  Therefore  "bad  air,"  which  gives  headaches,  makes 
people  drowsy,  etc.,  is  not  bad  from  lack  of  oxygen,  or  from 
too  much  carbonic  acid. 

13.  "  Bad  air  "  is  bad  from  too  much  humidity,  too  great 
heat,  or  both.  The  victims  of  the  Black  Hole  of  Calcutta 
died  of  "  heat  stroke,"  not  from  lack  of  oxygen  or  too  much 
carbonic  acid.  Suppose  you  run  an  automobile  without  any 
cooling  device!  Exactly  similar  is  the  effect  of  too  much 
heat  or  too  much  humidity,  or  both,  on  the  human  en- 
gine. 

14.  In  winter,  most  houses  are  too  dry.  This  means  ex- 
cessive evaporation  from  the  body,  chilling  it,  and  the  house 
must  be  heated  excessively  (to  70  or  75  degrees  Fahrenheit) 
to  make  up.  Evaporating  water  in  the  house  in  winter  to 
raise  the  humidity  from  30  per  cent,  (now  usual)  to  60  per 
cent,  (the  proper  figure)  reduces  the  temperature  necessary 
for  comfort  to  60  degrees  Fahrenheit;  and  saves  coal. 

15.  In  summer,  humidity,  as  well  as  heat,  is  too  high  as  a 
rule.  These  are  hard  to  control,  but  the  "  heat  and  humidity 
blanket"  which  we  ourselves  make  by  warming  up  the  air 
immediately  around  our  own  bodies  with  our  own  heat  and 
saturating  it  with  our  own  evaporated  sweat  can  be  dissi- 
pated by  a  breeze,  an  electric  fan,  or  moving  about  gently. 
In  winter  outdoors,  we  keep  our  "heat  and  humidity  blan- 
ket" close  to  our  skins  by  our  clothing. 

16.  Children,  especially  babies,  suffer  from  heat  and  hu- 
midity and  for  health  in  summer  require  light  clothing  or 
none,  and  circulation  of  air.  In  winter  they  need  warm, 
loose  clothing. 


APPENDIX  205 

No.  4.    MEDICAL  SUPEKVISION  OF  SCHOOLS 

1.  Medical  supervision  of  schools  means  a  physician  watch- 
ing over  the  children,  to  find  where  they  are  weak  in  their 
bodies;  and  to  prevent  outbreaks  of  infectious  diseases;  just 
as  the  teacher  watches  over  them  to  find  where  the  children 
are  weak  in  their  studies ;  and  to  prevent  disorder. 

2.  It  is  true  that  every  teacher  should  watch  the  children 
for  evident  bodily  defects,  poor  sight,  deafness,  sickness;  and 
should  report  these  to  the  principal,  or  school  board  for 
action.  But  teachers  are  not  trained  medical  men  and  can- 
not be  expected  to  do  such  work  perfectly. 

3.  The  best  system  of  medical  school  supervision  consists 
in  having  a  full-time  physician,  expert  in  this  work,  with  two 
trained  nurse  assistants.*  Such  supervision  has  two  main 
purposes:  I.  to  (a)  discover,  and  (b)  prevent  the  spread  of, 
infectious  diseases;  II.  to  (a)  discover,  and  (b)  provide  for 
the  correction  of,  physical  defects.     But  it  also  helps  in  — 

(a)  the  discovery  of  mental  peculiarities  of  the  children, 

(b)  the  discovery  of  unsanitary  conditions  in  the  school, 

(c)  the  provision  of  the  best  seating,  lighting,  heating, 

and  other  similar  matters, 

(d)  the  promotion  of  cleanliness,  order  and  decency. 
This  method  1.  prevents  epidemics, 

2.  promotes  general  health, 

3.  makes  a  safe,  sanitary  school. 

4.  Where  a  full-time  physician  specialist  cannot  be  se- 
cured, part  time  of  private  practising  physicians  helps;  but 
full-time  nurses  should  be  employed  as  well. 

5.  Where  only  one  inspection  can  be  secured  during  a 
school  year,  it  should  be  conducted  at  the  opening  of  the  fall 
term;  if  two,  at  the  opening  of  the  fall  term,  and  after  the 
Christmas  holidays.     These  single  inspections  — 

*  This  is  the  proportion  for  a  population  of  20,000. 


206  APPENDIX 

(a)  prevent  carrying  over  vacation  epidemics  into  the 

schools, 

(b)  help  to  detect  the  more  obvious  defects  and  disabili- 

ties of  the  children. 
They  do  not  aid  in  the  discovery  of  epidemics  during  the 
school  term ;  nor  in  the  detection  of  the  defects  or  disabilities 
developing  after  attendance  at  school  has  begun. 

6.  The  employment  of  school  nurses  alone,  without  any 
physician  as  supervisor,  accomplishes  a  good  deal  in  the  di- 
rection of  cleanliness,  the  following  up  of  obvioua  cases  of 
disease,  defect,  or  disability,  and  helps  in  truancy.  But  it 
neither  prevents  epidemics  nor  promotes  health,  mental  effi- 
ciency, or  general  sanitation  in  a  thorough-going  way. 

7.  Emergency  medical  supervision  is  conducted  in  epi- 
demics, to  detect  infected  children  and  protect  the  others. 
This  is  the  best  method  for  getting  rid  of  the  disease  and  it 
does  this  without  closing  the  schools:  it  can  be  done  in  any 
school,  at  any  time,  without  cost,  on  application  to  the  State 
Board  of  Health. 

8.  Medical  school  supervision  should  be  supplemented  by 
pre-school  supervision;  that  is,  supervision  of  prospective 
scholars,  children  now  under  school  age  who  will  later  go  to 
school;  and  by  instruction  to  mothers  before  and  after  the 
birth  of  their  children,  so  that  the  children  will  not  have  so 
many  defects  and  disabilities  to  correct  later. 

No.  1.    Germs  and  Disease,  should  be  taught  in  ALL  grades. 

No.  2.  Food  and  Water,  may  be  taught  in  whole  or  in 
part  to  all  grades. 

No.  3.    Air,  should  be  taught  in  the  sixth  and  higher  grades. 

No.  If..  Medical  School  Supervision,  should  be  taught  in 
the  eighth  and  higher  grades. 

PRINTED    IN    THE    UNITED    STATES    OF   AMERICA 


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